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	PH26851	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2140145	OTHER		PK

General Provider Information

NPI Number	:	1316289283
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	:	479-277-1242
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	10550 OLD SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-8660
Country	:	US
Telephone Number	:	904-380-8274
Fax Number	:	904-380-8275

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

Provider Enumeration Date	:	03/19/2013
Last Update Date	:	06/09/2025

Similar Medicare Providers

1144562232 — DR. AMY KRISTEN SOK PHARMD
Practice Location Address:

10550 OLD SAINT AUGUSTINE RD
JACKSONVILLE, FL
32257-8660

Practice Phone: 904-380-8274
Practice Fax:

1952869505 — ELIZABETH MARIE WILLIAMS RPH
Practice Location Address:

10550 OLD SAINT AUGUSTINE RD
JACKSONVILLE, FL
32257-8660

Practice Phone: 904-380-8274
Practice Fax:

1073157392 — AMANDA D HAMMOCK PHARMD
Practice Location Address:

10550 OLD SAINT AUGUSTINE RD
JACKSONVILLE, FL
32257-8660

Practice Phone: 904-380-8274
Practice Fax:

1124963350 — PATRIOTMED OF KANSAS, P.A.
Practice Location Address:

3030 HARTLEY RD STE 140
JACKSONVILLE, FL
32257-8210

Practice Phone: 904-475-2365
Practice Fax:

1629832605 — SHA-LONDA GARY
Practice Location Address:

4243 SUNBEAM RD STE 1
JACKSONVILLE, FL
32257-8975

Practice Phone: 855-284-7483
Practice Fax:

1225867070 — DAVID BRADSHAW
Practice Location Address:

3750 SAN JOSE PL STE 34
JACKSONVILLE, FL
32257-8861

Practice Phone: 904-902-8981
Practice Fax: 904-906-1237

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.