Organization
WAL-MART STORES EAST LP
Active
Other names
Wal-Mart Pharmacy 10-3804
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
8730 LIBERTY RD, RANDALLSTOWN, MD 21133-4710
(443) 576-3155
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-6209
(479) 277-1242
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P05760
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2136614
PK
—
05
—
331569000
—
MD
05
—
448237900
—
MD
Enumeration date
08/21/2012
Last updated
07/08/2025
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