Healthcare Provider Details

I. General information

NPI: 1720506967
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 S WOODLAND BLVD
DELAND FL
32720-7321
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 386-624-0679
  • Fax: 386-624-0680
Mailing address:
  • Phone: 479-277-2500
  • Fax: 479-277-4331

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 NumberPH31103
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR, ENROLLMENT
Credential:
Phone: 480-277-6348