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General NPI Number Information
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NPI Number | 1144564782
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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 | 11/20/2012
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Last Update Date | 06/18/2025
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Provider Practice Location Address
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Address Line | 6111 JEFFERSON AVE
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City | NEWPORT NEWS
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State | VA
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Zip | 23605-1511
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Country | US
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Telephone | 757-637-4217
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Fax |
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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 | 479-204-0709
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Fax | 479-277-4331
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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 | 480-853-0515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 0201004494
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License Number State | VA
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