Healthcare Provider Details

I. General information

NPI: 1417883091
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 E MAIN ST
LAURENS SC
29360-3616
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-682-8111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

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