NPIMap

Wal-Mart Stores East LP

Organization Active NPI Community/Retail Pharmacy · Pisgah Forest, NC

NPI 1033136296 · NPPES record last updated Jun 17, 2025

Key facts

NPI
1033136296
Entity type
Organization (NPI type 2)
Primary specialty
Community/Retail Pharmacy 3336C0003X
License
7997 (NC)
Legal business name
WAL-MART STORES EAST LP
Practice address
177 Forest Gate Dr
Pisgah Forest, NC 28768-7903
Phone
(828) 885-7904
Fax
(828) 884-3442
NPI assigned
Jul 16, 2006
Organization subpart
No

Authorized official

Name
Kimberly Canonic
Title
Senior Director, Enrollment
Phone
(480) 853-0515

Corporate family (same tax ID) 21

Organizations that report the same tax identification number in the National Provider Directory.

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2139147Walmart Pharmacy 10-1795
177 Forest Gate Drive, Pisgah Forest, NC 28768		Certificate of waiverOct 30, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-1795
177 Forest Gate Ctr, Pisgah Forest, NC 28768-7903 · (828) 885-7904		 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Enteral Nutrients|Surgical Dressings Does not accept assignment
Participating since Jul 1, 2014

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in NC

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20100930060601 NC DME Supplier - Pharmacy 6204749997 Practice locations: Pisgah Forest, NC
O20130724000619 NC Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment

National Provider Directory

Tax ID family
Ability Network (4,651 organizations share this tax ID)

Locations

100 FRST Gate Ctr
Pisgah Forest, NC 28768

177 Forest Gate Dr
Pisgah Forest, NC 28768
Phone (828) 885-7904

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 7997 NC Yes

Addresses

Primary practice location

177 Forest Gate Dr
Pisgah Forest, NC 28768-7903

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1240

Other identifiers

IdentifierTypeStateIssuer
0855178MedicaidNC
7704108MedicaidNC
2070385OtherPK
855178MedicaidNC

Other names

  • WALMART PHARMACY 10-1795 Doing business as

Electronic endpoints

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jun 17, 2025.

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750118400000",
    "number": "1033136296",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-277-1240",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "177 FOREST GATE DR",
            "city": "PISGAH FOREST",
            "state": "NC",
            "postal_code": "287687903",
            "telephone_number": "828-885-7904",
            "fax_number": "828-884-3442"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-06-17",
        "certification_date": "2025-06-17",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NC",
            "license": "7997",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0855178",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7704108",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2070385",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "855178",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "WALMART PHARMACY 10-1795",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pisgah Forest, NC

All providers in Pisgah Forest, NC · Community/Retail Pharmacy in North Carolina

Sources for this page

Verify at the official NPI Registry.