Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-5408
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3805 S KEYSTONE AVE, INDIANAPOLIS, IN 46227-3540
(317) 786-3820
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
60005842A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200362680
—
IN
05
—
200362680A
—
IN
01
—
2025202
PK
—
Enumeration date
07/16/2006
Last updated
06/13/2025
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