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	60006031A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2025468	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417041575
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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2347 VETERANS MEMORIAL PKWY S
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-9183
Country	:	US
Telephone Number	:	765-477-9391
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2025

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