Walmart Inc.
Organization Active NPI Community/Retail Pharmacy · Shenandoah, IA
NPI 1093732471 · NPPES record last updated Jul 8, 2025
Key facts
- NPI
- 1093732471
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 202 (IA)
- Legal business name
- WALMART INC.
- Practice address
- 705 S Fremont St
Shenandoah, IA 51601-2101 - Phone
- (712) 246-4033
- 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) 18
Practitioners 5
-
Barbara Ann Boston, PHARMD
-
Brant Donald Hanisch, PHARM.D.
-
Heidi Joy Hanisch, PHARMD
-
Ammon Niels Landon Mitchell, PHARMD
-
Justin David Thomas, PHARMD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 16D2128863 | Walmart Pharmacy 10-1683 | Certificate of waiver | Apr 9, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Wal Mart Pharmacy 10-1683 |
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 IA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930050929 | IA | DME Supplier - Pharmacy | 4385556745 | Practice locations: Shenandoah, IA |
| O20131029001699 | IA | Part B Supplier - Mass Immunization (Roster Biller Only) | 4385556745 | This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Ability Network
Locations
705 S Fremont St
Shenandoah, IA 51601
Phone (712) 246-4033
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 202 | IA | Yes |
Addresses
Primary practice location
705 S Fremont St
Shenandoah, IA 51601-2101
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0078667 | Medicaid | IA | |
| 2028876 | Other | PK | |
| 78667 | Medicaid | IA |
Other names
- WALMART PHARMACY 10-1683
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 Shenandoah, IA
- Jillian Marie Travis
- Urology Center, PC
- Shelby Marie Vanleuven
- Vantage Rehab Inc
- Kala Varellas
- Rose Walter
- Karen Webster
- Robert Weidman
- Kindra A Weston
- Kay Blois Wing
All providers in Shenandoah, IA · Community/Retail Pharmacy in Iowa
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 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.