=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528475597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART STORES EAST, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2014
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6855 WILSON BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-513-6627
-----------------------------------------------------
Fax | 904-513-6628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST MAILSTOP 0445
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-277-1242
-----------------------------------------------------
Fax | 479-277-4331
-----------------------------------------------------
=====================================================
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 | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH28632
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------