MEDICARE: WAL-MART STORES EAST LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	16691	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2160442	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235586884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST LP

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:	MAILSTOP 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-204-8550
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	3915 N KINGS HWY
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-2742
Country	:	US
Telephone Number	:	843-353-5589
Fax Number	:	843-353-5588

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-277-6348

Provider Enumeration Date	:	05/24/2016
Last Update Date	:	06/09/2025

Similar Medicare Providers

1568819340 — DR. STEPHANIE CHAYCE VANCE-CROTTS
Practice Location Address:

3915 N KINGS HWY
MYRTLE BEACH, SC
29577-2742

Practice Phone: 843-353-5589
Practice Fax: 843-353-5588

1730539057 — STEVE KEEN RPH
Practice Location Address:

3915 N KINGS HWY
MYRTLE BEACH, SC
29577-2742

Practice Phone: 843-839-9875
Practice Fax:

1588912729 — MRS. JANIENE TWARDY
Practice Location Address:

140 SAYEBROOK PKWY , T-2742
MYRTLE BEACH, SC
29588-6834

Practice Phone: 843-294-6572
Practice Fax:

1457031197 — MELISSA R LEE
Practice Location Address:

2742 ETON ST
MYRTLE BEACH, SC
29579-6714

Practice Phone: 843-685-0346
Practice Fax:

1104871938 — DR. CAMERON KHAVARIAN M.D.
Practice Location Address:

320 SUPERIOR AVENUE , SUITE 320
NEWPORT BEACH, CA
92663-2742

Practice Phone: 949-645-8475
Practice Fax: 855-213-1762

1528138823 — CAMERON KHAVRIAN, MD INC
Practice Location Address:

320 SUPERIOR AVENUE , SUITE 320
NEWPORT BEACH, CA
92663-2742

Practice Phone: 949-645-8475
Practice Fax: 855-213-1762

Directions to “WAL-MART STORES EAST LP ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2025 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.