Healthcare Provider Details

I. General information

NPI: 1851333090
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ROCKY BOTTOM DR
UNICOI TN
37692-4030
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-9998
  • Fax: 423-743-8087
Mailing address:
  • Phone: 479-204-8550
  • 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 Number4278
License Number StateTN

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR ENROLMENT
Credential:
Phone: 480-853-0515