Provider Demographics
NPI:1588431613
Name:WAL-MART STORES EAST, LP.
Entity type:Organization
Organization Name:WAL-MART STORES EAST, LP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR
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:479-371-1168
Mailing Address - Street 1:1 CUSTOMER DR, MS 0445
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:
Mailing Address - Fax:
Practice Address - Street 1:1275 N AZUSA AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1246
Practice Address - Country:US
Practice Address - Phone:626-331-1570
Practice Address - Fax:626-331-6815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty