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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	6006578A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164027	OTHER		PK

General Provider Information

NPI Number	:	1205380474
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	:	MAILSTOP 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-6209
Country	:	US
Telephone Number	:	479-204-8550
Fax Number	:	479-204-8550

Provider Business Practice Location Address
First Line	:	1309 E HACKBERRY ST
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-9604
Country	:	US
Telephone Number	:	812-883-8722
Fax Number	:	812-883-7814

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-277-6348

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	06/09/2025

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