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NPI Code Detail

MEDICARE: WAL-MART STORES EAST LP

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
13336C0003XCommunity/Retail Pharmacy00005487TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12150359OTHERPK

General Provider Information

NPI Number : 1831580885
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 : 140 JOE B JACKSON PKWY
Second Line :
City : MURFREESBORO
State : TN
Zip : 37127-7228
Country : US
Telephone Number : 615-907-8999
Fax Number : 615-907-8998
Authorized Official
Title or Position : SENIOR DIRECTOR, ENROLLMENT
Name : KIMBERLY CANONIC
Credential :
Telephone Number : 480-277-6348
Provider Enumeration Date : 02/12/2015
Last Update Date : 06/02/2025

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