Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1580
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
10617 E WASHINGTON ST, INDIANAPOLIS, IN 46229-2611
(317) 895-0316
Mailing address
702 SW 8TH ST, MAIL STOP 0445, 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
60005069
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100292100A
—
IN
01
—
2027174
PK
—
Enumeration date
07/19/2006
Last updated
07/14/2025
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