Healthcare Provider Details
I. General information
NPI: 1013934413
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 07/16/2006
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:
III. Provider practice location address
2354 COMMERCE PARK DR STE 100
ORLANDO FL
32819-8601
US
IV. Provider business mailing address
702 SW 8TH ST
BENTONVILLE AR
72716-0445
US
V. Phone/Fax
- Phone: 877-453-4566
- Fax: 866-537-0877
- Phone: 479-277-1242
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 965 |
| License Number State | ND |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | PHA-MOP-LIC-12447 |
| License Number State | MT |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 262265 |
| License Number State | MN |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | FL873 |
| License Number State | KY |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 054.015021 |
| License Number State | IL |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 64000468A |
| License Number State | IN |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | PHY.005063-OS |
| License Number State | LA |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 22601 |
| License Number State | TX |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 3872 |
| License Number State | TN |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 5301007714 |
| License Number State | MI |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 2003010214 |
| License Number State | MO |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 99-6096 |
| License Number State | OK |
| # 13 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | PH18943 |
| License Number State | FL |
| # 14 | |
| Primary Taxonomy | N |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | 021368750-03 |
| License Number State | OH |
| # 15 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 3336S0011X |
| Taxonomy | Specialty Pharmacy |
| License Number | OS01543 |
| License Number State | AR |
VIII. Authorized Official
Name:
KIMBERLY
CANONIC
Title or Position: SENIOR DIRECTOR, ENROLLMENT
Credential:
Phone: 479-371-1168
