=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609818673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART STORES EAST LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 06/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4250 PHILIPS HWY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-6730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-737-7001
-----------------------------------------------------
Fax | 479-277-4331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR, ENROLLMENT
-----------------------------------------------------
Name | KIMBERLY CANONIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-853-0515
-----------------------------------------------------
=====================================================
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 | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH22042
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------