Healthcare Provider Details

I. General information

NPI: 1275409302
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 SE MARICAMP RD
OCALA FL
34471-6247
US

IV. Provider business mailing address

1 CUSTOMER DR
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 352-390-1115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
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: 480-277-6348