Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-3628
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
115 HIGHWAY 14, SIMPSONVILLE, SC 29681-6051
(864) 757-7079
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 277-2500
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
15564
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2148883
PK
—
05
—
715564
—
SC
Enumeration date
10/15/2014
Last updated
06/10/2025
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