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NPI Code Detail

MEDICARE: WAL-MART STORES EAST LP

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
1332B00000XDurable Medical Equipment & Medical Supplies
23336C0003XCommunity/Retail Pharmacy7-7474OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22154955OTHERPK

General Provider Information

NPI Number : 1316318934
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 : 72716-6209
Country : US
Telephone Number : 479-204-8550
Fax Number : 479-277-4331
Provider Business Practice Location Address
First Line : 13503 S SANTE FE AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73170-7314
Country : US
Telephone Number : 405-300-6418
Fax Number : 405-300-6417
Authorized Official
Title or Position : SENIOR DIRECTOR, ENROLLMENT
Name : KIMBERLY CANONIC
Credential :
Telephone Number : 480-277-6348
Provider Enumeration Date : 10/08/2015
Last Update Date : 06/10/2025

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1124985569 — TAM PHAM
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Directions to “WAL-MART STORES EAST LP ” Practice Location

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