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General NPI Number Information
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NPI Number | 1376560623
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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 | 06/19/2025
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Provider Practice Location Address
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Address Line | 3435 CENTERVILLE HWY
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City | SNELLVILLE
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State | GA
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Zip | 30039-6117
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Country | US
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Telephone | 770-972-3135
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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 |
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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 | 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 | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE008999
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License Number State | GA
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