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	2002009665	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2050579	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871510115
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	:

Provider Business Practice Location Address
First Line	:	4252 OSAGE BEACH PKWY
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-2171
Country	:	US
Telephone Number	:	573-348-4095
Fax Number	:

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

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	06/03/2025

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