Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-0492
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
650 KIMMELL RD, VINCENNES, IN 47591-6341
(812) 886-0006
Mailing address
702 SW 8TH ST, 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
60005020A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2026756
PK
—
05
—
300023350
—
IN
05
—
300023350DME
—
IN
Enumeration date
07/16/2006
Last updated
06/02/2025
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