Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1666
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3850 E INDEPENDENCE BLVD, CHARLOTTE, NC 28205-7305
(704) 535-7954
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
07947
NC
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0607440
—
NC
01
—
2070257
PK
—
05
—
607440
—
NC
05
—
7704029
—
NC
Enumeration date
07/16/2006
Last updated
07/09/2025
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