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	11102	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2125156	OTHER		PK

General Provider Information

NPI Number	:	1326366493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST LP

Provider Business Mailing Address
First Line	:	1 CUSTOMER DR
Second Line	:	MS 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-1238
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 HIGHWAY 274
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-6045
Country	:	US
Telephone Number	:	803-619-7028
Fax Number	:	803-619-7022

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-853-0515

Provider Enumeration Date	:	05/13/2010
Last Update Date	:	09/29/2025

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