Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-0239
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
220 VETERANS MEMORIAL DR, KOSCIUSKO, MS 39090-3848
(662) 289-4593
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
04110
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00920722
—
MS
05
—
07839727
—
MS
01
—
2045796
PK
—
05
—
7839727
—
MS
Enumeration date
07/17/2006
Last updated
07/03/2025
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