Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-4399
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
30830 OLD US 20, ELKHART, IN 46514-9481
(574) 674-5730
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
600006113A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200892960A
—
IN
01
—
2025764
PK
—
Enumeration date
01/16/2008
Last updated
07/10/2025
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