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	PH29355	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2153273	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245619238
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	:	72716-0445
Country	:	US
Telephone Number	:	479-204-8550
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	3400 E LAKE RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-2401
Country	:	US
Telephone Number	:	727-431-1419
Fax Number	:	727-431-1418

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-853-0515

Provider Enumeration Date	:	05/22/2015
Last Update Date	:	06/18/2025

Similar Medicare Providers

1215942412 — WALGREEN CO
Practice Location Address:

3420 E LAKE RD
PALM HARBOR, FL
34685-2401

Practice Phone: 727-785-7451
Practice Fax:

1578633442 — EAST LAKE EYECARE & EYEWEAR INC
Practice Location Address:

3434 E LAKE RD STE 3
PALM HARBOR, FL
34685-2401

Practice Phone: 727-781-7922
Practice Fax:

1326161373 — MR. LAWRENCE MICHAEL HARKINS DMD
Practice Location Address:

3410 E LAKE RD
PALM HARBOR, FL
34685-2401

Practice Phone: 727-784-6700
Practice Fax:

1669668653 — BENDER EYECARE
Practice Location Address:

3434 E LAKE RD , SUITE #3
PALM HARBOR, FL
34685-2401

Practice Phone: 727-781-7922
Practice Fax: 727-789-9859

1508136938 — VISHAL MODI MS RPH
Practice Location Address:

3420 E LAKE RD
PALM HARBOR, FL
34685-2401

Practice Phone: 727-785-7451
Practice Fax: 727-772-5547

1922647189 — KRIS ELAINE SOSA
Practice Location Address:

3400 E LAKE RD
PALM HARBOR, FL
34685-2401

Practice Phone: 727-431-1419
Practice Fax:

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

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.