Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Waverly, TN
NPI 1073530267 · NPPES record last updated May 30, 2025
Key facts
- NPI
- 1073530267
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- C2897 (TN)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 275 Walton Dr
Waverly, TN 37185-3382 - Phone
- (931) 296-9984
- Fax
- (931) 296-9986
- NPI assigned
- Jul 16, 2006
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 277-6348
Corporate family (same tax ID) 24
Member of 2
Practitioners 5
-
Heather Moore Brown, PHARMD
-
Lacey Dunkley Freeman I, PHARMD
-
Kaitlyn Monsue, PHARMD
-
Kimberley Oatsvall Townsend, PHARMD
-
Ambra Lynn Wilson, PHARM. D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D2140017 | Walmart Pharmacy 10-0390 | Certificate of waiver | Nov 13, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Walmart Pharmacy 10-0390 |
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 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930087608 | TN | DME Supplier - Pharmacy | 6204749997 | Practice locations: Waverly, TN |
| O20130808000651 | TN | 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
Locations
275 Walton Dr
Waverly, TN 37185
Phone (931) 296-9984
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | C2897 | TN | Yes |
Addresses
Primary practice location
275 Walton Dr
Waverly, TN 37185-3382
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-8550
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2091600 | Other | PK | |
| 1454020 | Medicaid | TN |
Other names
- WALMART PHARMACY 10-0390
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 Waverly, TN
- Olivia Paige Trull
- Marlene Upchurch
- Valley Physical Therapy
- Kathy Michelle Vann
- Tracy W. Vine
- Jessica Nicole Waldrop
- Susan Warren
- Waverly Clinic PC
- Waverly Health Care and Rehabilitation Center, LLC
- Waverly Pediatric and Adult Care
All providers in Waverly, TN · Community/Retail Pharmacy in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 30, 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.