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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
13336C0003XCommunity/Retail Pharmacy0201004494VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22138057OTHERPK

General Provider Information

NPI Number : 1144564782
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 : 479-204-0709
Fax Number : 479-277-4331
Provider Business Practice Location Address
First Line : 6111 JEFFERSON AVE
Second Line :
City : NEWPORT NEWS
State : VA
Zip : 23605-1511
Country : US
Telephone Number : 757-637-4217
Fax Number :
Authorized Official
Title or Position : SENIOR DIRECTOR, ENROLLMENT
Name : KIMBERLY CANONIC
Credential :
Telephone Number : 480-853-0515
Provider Enumeration Date : 11/20/2012
Last Update Date : 06/18/2025

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