Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3362
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
14800 FORT CAMPBELL BLVD, OAK GROVE, KY 42262-8304
(270) 640-5848
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
P07066
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2034332
PK
—
05
—
54011036
—
KY
05
—
5401103600
—
KY
05
—
P07066
—
KY
Enumeration date
07/16/2006
Last updated
06/19/2025
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