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General NPI Number Information
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NPI Number | 1013934413
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Entity Type | Organization
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Legal Business Name | WAL-MART STORES EAST LP
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Dates
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Enumeration Date | 07/16/2006
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 2354 COMMERCE PARK DR STE 100
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City | ORLANDO
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State | FL
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Zip | 32819-8601
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Country | US
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Telephone | 877-453-4566
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Fax | 866-537-0877
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Provider Business Mailing Address
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Address Line | 702 SW 8TH ST
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City | BENTONVILLE
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State | AR
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Zip | 72716-0445
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Country | US
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Telephone | 479-277-1242
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Fax |
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Authorized Official
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Title or Position | SENIOR DIRECTOR, ENROLLMENT
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Name | KIMBERLY CANONIC
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Credential |
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Telephone | 479-371-1168
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 965
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | PHA-MOP-LIC-12447
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License Number State | MT
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Taxonomy #3
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 262265
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | FL873
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License Number State | KY
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Taxonomy #5
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 054.015021
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License Number State | IL
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Taxonomy #6
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 64000468A
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License Number State | IN
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Taxonomy #7
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | PHY.005063-OS
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License Number State | LA
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Taxonomy #8
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 22601
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License Number State | TX
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Taxonomy #9
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 3872
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License Number State | TN
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Taxonomy #10
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 5301007714
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License Number State | MI
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Taxonomy #11
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 2003010214
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License Number State | MO
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Taxonomy #12
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 99-6096
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License Number State | OK
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Taxonomy #13
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | PH18943
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License Number State | FL
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Taxonomy #14
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 021368750-03
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License Number State | OH
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Taxonomy #15
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | OS01543
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License Number State | AR
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