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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
2333600000XPharmacy
33336C0003XCommunity/Retail PharmacyPHRE008004GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12019341OTHERPK
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1457379927
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 :
Fax Number :
Provider Business Practice Location Address
First Line : 1550 RIVERSTONE PKWY
Second Line :
City : CANTON
State : GA
Zip : 30114-2918
Country : US
Telephone Number : 770-479-9003
Fax Number :
Authorized Official
Title or Position : SENIOR DIRECTOR, ENROLLMENT
Name : KIMBERLY CANONIC
Credential :
Telephone Number : 480-277-6348
Provider Enumeration Date : 07/17/2006
Last Update Date : 06/02/2025

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

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