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	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	114567	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2155149	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629448451
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	:	479-277-1242
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	3864 US HIGHWAY 80 W
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-6526
Country	:	US
Telephone Number	:	334-408-6068
Fax Number	:	334-408-6067

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

Provider Enumeration Date	:	10/06/2015
Last Update Date	:	06/10/2025

Similar Medicare Providers

1356863138 — MAROUENE MELKI PHARMD
Practice Location Address:

3864 US HIGHWAY 80 W
PHENIX CITY, AL
36870-6526

Practice Phone: 334-408-6068
Practice Fax: 334-408-6067

1528625183 — SAMANTHA SMITH
Practice Location Address:

3864 US HIGHWAY 80 W
PHENIX CITY, AL
36870-6526

Practice Phone: 334-408-6068
Practice Fax:

1376296624 — DAVID LEE RIVENBARK III PHARMD
Practice Location Address:

3864 US HIGHWAY 80 W
PHENIX CITY, AL
36870-6526

Practice Phone: 334-408-6069
Practice Fax:

1356208771 — LAURIE ANN HAYES RN
Practice Location Address:

1105 LEE ROAD 425
PHENIX CITY, AL
36870-7519

Practice Phone: 706-888-4092
Practice Fax:

1043250327 — MICHAEL W JOHNSTON M.D.
Practice Location Address:

7 WINDSWEEP CT
PHENIX CITY, AL
36870-2336

Practice Phone: 334-297-5555
Practice Fax: 334-297-5525

1538279781 — MRS. AMY M REAVES
Practice Location Address:

3952 US HIGHWAY 80 W
PHENIX CITY, AL
36870-6523

Practice Phone: 334-214-9129
Practice Fax: 334-214-9640

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.