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	3336C0003X	Community/Retail Pharmacy	PHY.007019-RC	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2148770	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285030098
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	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-204-8705
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	260 SAM HOUSTON JONES PKWY
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5603
Country	:	US
Telephone Number	:	337-214-6402
Fax Number	:	337-214-6403

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

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	06/10/2025

Similar Medicare Providers

1972533602 — DR. SANDRA DENISE MARY BRUNO M.D.
Practice Location Address:

217 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-217-1000
Practice Fax: 337-217-1004

1295868024 — SANDRA D.M. BRUNO, M.D., LLC
Practice Location Address:

217 SAM HOUSTON JONES PKWY , SUITE 101
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-217-1000
Practice Fax:

1821255852 — DR. PENNY LYNN GOODWIN M.D.
Practice Location Address:

237 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-855-3438
Practice Fax: 337-855-9488

1376901694 — CALCASIEU URGENT CARE LLC
Practice Location Address:

242 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-905-4000
Practice Fax: 337-905-4003

1013421577 — DERRIAN SMITH PHARMD
Practice Location Address:

260 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-214-6401
Practice Fax:

1215573308 — JONATHAN HUYNH
Practice Location Address:

260 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA
70611-5603

Practice Phone: 337-214-6402
Practice Fax:

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 © 2007-2026 (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.