=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154348381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART STORES EAST LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 ROUTE 9W
-----------------------------------------------------
City | GLENMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12077-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-432-1747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-277-1242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR, ENROLLMENT
-----------------------------------------------------
Name | KIMBERLY CANONIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-277-6348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 26457
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------