Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-4472
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
8424 MALL PKWY, LITHONIA, GA 30038-2979
(770) 225-0394
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-2500
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009956
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003139004A
—
GA
01
—
2141674
PK
—
Enumeration date
08/13/2013
Last updated
07/14/2025
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