Provider Demographics
NPI:1528584083
Name:WAL-MART STORES EAST LP
Entity type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANONIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-277-6348
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-277-9170
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:2855 N OLD LAKE WILSON ROAD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747
Practice Address - Country:US
Practice Address - Phone:407-606-0111
Practice Address - Fax:407-606-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies