Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3401
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
6149 OLD NATIONAL HWY, COLLEGE PARK, GA 30349-4479
(770) 994-0199
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
PHRE009106
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2016414
PK
—
05
—
710232045A
—
GA
Enumeration date
12/27/2006
Last updated
06/19/2025
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