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	2-7368	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2153495	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275913352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST , LP

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

Provider Business Practice Location Address
First Line	:	11551 N 129TH EAST AVE
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-7446
Country	:	US
Telephone Number	:	918-371-3585
Fax Number	:	918-371-3733

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	04/10/2026

Similar Medicare Providers

1568067320 — DR. GRACE WOLFENDALE PHARMD
Practice Location Address:

11551 N 129TH EAST AVE
OWASSO, OK
74055-7446

Practice Phone: 918-371-3584
Practice Fax:

1992640833 — GABRIELA SUMMERLIN
Practice Location Address:

8787 N OWASSO EXPY STE E
OWASSO, OK
74055-4482

Practice Phone: 918-516-2211
Practice Fax:

1205495421 — CAITLYN A LEWIS
Practice Location Address:

108 W 1ST AVE STE C
OWASSO, OK
74055-3137

Practice Phone: 855-223-7123
Practice Fax:

1972450724 — COVENANT HELP CHRISTIAN COUNSELING
Practice Location Address:

8787 N 97TH EAST AVE APT 106
OWASSO, OK
74055-6891

Practice Phone: 918-907-2113
Practice Fax:

1962144774 — LINZIE HOPKINS
Practice Location Address:

11510 N 109TH EAST AVE
OWASSO, OK
74055-4265

Practice Phone: 918-693-1039
Practice Fax:

1205371028 — NANDEE WALKER NCC, LPC-S, RPT-S
Practice Location Address:

10310 N 138TH EAST AVE STE 104
OWASSO, OK
74055-4611

Practice Phone: 918-408-6893
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.