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NPI Code Detail

MEDICARE: WAL-MART STORES EAST LP

MEDICARE: WAL-MART STORES EAST LP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
33336C0003XCommunity/Retail PharmacyPHRE006608GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22015034OTHERPK

General Provider Information

NPI Number : 1114944527
Entity Type Code : Organization
Provider Name (Legal Business Name) : WAL-MART STORES EAST LP
Provider Business Mailing Address
First Line : 702 SW 8TH ST
Second Line :
City : BENTONVILLE
State : AR
Zip : 72716-0445
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 15328 US HIGHWAY 19 S
Second Line :
City : THOMASVILLE
State : GA
Zip : 31757-4824
Country : US
Telephone Number : 229-228-5771
Fax Number :
Authorized Official
Title or Position : SENIOR DIRECTOR, ENROLLMENT
Name : KIMBERLY CANONIC
Credential :
Telephone Number : 480-277-6348
Provider Enumeration Date : 07/16/2006
Last Update Date : 06/04/2025

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Directions to “WAL-MART STORES EAST LP ” Practice Location

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