Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-3843
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
610 LEGION RD, DENTON, MD 21629-2040
(410) 479-0758
(410) 479-0812
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-6209
(479) 277-9170
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
Primary
P05803
MD
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2136649
PK
—
05
—
678902100
—
MD
Enumeration date
08/22/2012
Last updated
07/08/2025
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