Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-5310
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
15047 AIRLINE HWY, PRAIRIEVILLE, LA 70769
(225) 744-8409
(225) 744-8411
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 204-1258
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
Primary
PHY.007459-RC
LA
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2168009
PK
—
Enumeration date
02/06/2017
Last updated
06/10/2025
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