Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-4278
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
1001 WARRIOR WAY, QUINCY, WV 25015-1300
(304) 220-3008
Mailing address
702 SW 8TH ST, MAIL STOP 0445, BENTONVILLE, AR 72716-0445
(479) 277-1242
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
MP0552413
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2131052
PK
—
05
—
3810022638
—
WV
Enumeration date
07/08/2011
Last updated
07/09/2025
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