Healthcare Provider Details

I. General information

NPI: 1235041054
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41176 HWY 27
DAVENPORT FL
33837-1005
US

IV. Provider business mailing address

1 CUSTOMER DR # MS 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 479-277-3665
  • Fax:
Mailing address:
  • Phone: 479-277-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: DIRECTOR OF HEALTH CARE CONTRACTING
Credential:
Phone: 480-853-0515