Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-0803
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
401 ONTARIO AVE, BOGALUSA, LA 70427-2610
(985) 732-7677
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
PHY006282-RC
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2126230
PK
—
05
—
220321
—
LA
Enumeration date
08/11/2010
Last updated
06/03/2025
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