Healthcare Provider Details

I. General information

NPI: 1689084287
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 GA HIGHWAY 26 E
COCHRAN GA
31014-6049
US

IV. Provider business mailing address

702 SW 8TH ST MAILSTOP 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-4735
  • Fax: 478-934-7942
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 Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010053
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2146018
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier003150069A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

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