Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Gardner, MA
NPI 1003833302 · NPPES record last updated Jun 3, 2025
Key facts
- NPI
- 1003833302
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- CS2739 (MA)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 677 Timpany Blvd
Gardner, MA 01440-3452 - Phone
- (978) 630-1352
- NPI assigned
- Jul 16, 2006
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 277-6348
Other NPIs on the same Medicare enrollment 47
Corporate family (same tax ID) 13
Member of 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930048217 | MA | DME Supplier - Pharmacy |
6204749997 | Practice locations: Gardner, MA |
| O20150115002399 | MA | Part B Supplier - Mass Immunization (Roster Biller Only) | 6204749997 |
48 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Northampton, MA; Northborough, MA; Orange, MA; Pittsfield, MA; Plymouth, MA; Quincy, MA; Raynham, MA; Salem, MA… |
National Provider Directory
- Tax ID family
- Ability Network
Locations
677 Timpany Blvd
Gardner, MA 01440
Phone (978) 630-1352
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | CS2739 | MA | Yes |
Addresses
Primary practice location
677 Timpany Blvd
Gardner, MA 01440-3452
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0446203 | Medicaid | MA | |
| 446203 | Medicaid | MA | |
| 2037474 | Other | PK |
Other names
- WAL-MART PHARMACY 10-2155
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
Other providers in Gardner, MA
- Tina Vo
- Tricia L Vorderstrasse
- Huy Duc Vu
- Wachusett Radiology, Inc.
- Wachusett Rehabilitation and Nursing Center LLC
- Wal-Mart Stores East, LP
- Bonnie Lyn Waldron
- Joseph W Walek
- Walgreen Co
- Walgreen Co
All providers in Gardner, MA · Community/Retail Pharmacy in Massachusetts
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 3, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.