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
1	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy

General Provider Information

NPI Number	:	1124996491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST, LP

Provider Business Mailing Address
First Line	:	1 CUSTOMER DR
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10000 OMNI DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-4171
Country	:	US
Telephone Number	:	904-934-6904
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF HEALTH CARE CONTRACTING
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-277-6348

Provider Enumeration Date	:	10/28/2025
Last Update Date	:	10/28/2025

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