Organization
WAL-MART STORES EAST , LP
Active
Other names
Walmart Pharmacy 10-6166
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
10290 DIBERVILLE BLVD, DIBERVILLE, MS 39540-2536
(228) 271-6753
(228) 271-6757
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
13428/ 1.2
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02879529
—
MS
01
—
2147300
PK
—
Enumeration date
08/08/2014
Last updated
06/09/2025
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