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	23342	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2060204	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962429100
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	:	750 MIDDLE COUNTRY RD
Second Line	:
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953-2542
Country	:	US
Telephone Number	:	631-924-0154
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

Similar Medicare Providers

1558365585 — ALAN ELLMAN - HARVEY LINDENBAUM DDS
Practice Location Address:

770 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-924-7997
Practice Fax: 631-924-7953

1255378162 — NATIONAL VISION, INC.
Practice Location Address:

750 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-345-0065
Practice Fax:

1750421368 — DR. TODD MICHAEL MAYER
Practice Location Address:

770 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-924-7997
Practice Fax:

1083803589 — MR. FRANK SCIORTINO R.PH.
Practice Location Address:

750 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-924-0154
Practice Fax:

1932383395 — MS. THERESA A SOWINSKI
Practice Location Address:

750 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-924-0154
Practice Fax:

1912141565 — DONNA M GOENNER OPTICIAN
Practice Location Address:

750 MIDDLE COUNTRY RD
MIDDLE ISLAND, NY
11953-2542

Practice Phone: 631-345-0065
Practice Fax: 631-345-0138

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.