NPIMap

Organization Active NPI

Wal-Mart Stores East LP

  • Pharmacy
  • Aberdeen, MD
National Provider Identifier
1174540447
Registry record updated Jun 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
P01777 Issued in MD
Legal business name
WAL-MART STORES EAST LP
Practice address
645 S Philadelphia Blvd
Aberdeen, MD 21001-3613
Phone
(410) 273-9203
Fax
(410) 273-9205
NPI assigned
Jul 16, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kimberly Canonic
Title
Senior Director, Enrollment
Phone
(480) 277-6348

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X P01777 MD Primary
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

645 S Philadelphia Blvd
Aberdeen, MD 21001-3613

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-9170

Other identifiers 2

IdentifierTypeStateIssuer
2034796OtherPK
468004900MedicaidMD

Other names 1

  • WALMART PHARMACY 10-1968 Doing business as

Electronic endpoints 1

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930018550 MD DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Aberdeen, MD
O20141021001909 MD Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 47 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Glen Burnie, MD; Sykesville, MD; Hagerstown, MD; Hampstead, MD; Hanover, MD; La Plata, MD; Laurel, MD; Lavale, MD…

Other NPIs on the same Medicare enrollment 46

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 46

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
21D2157602Walmart Pharmacy 10-1968645 S Philadelphia Boulevard, Aberdeen, MD 21001Certificate of waiverNov 7, 2026

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,651 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 2

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

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749427200000",
    "number": "1174540447",
    "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": "479-277-9170"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "645 S PHILADELPHIA BLVD",
            "city": "ABERDEEN",
            "state": "MD",
            "postal_code": "210013613",
            "telephone_number": "410-273-9203",
            "fax_number": "410-273-9205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-06-09",
        "certification_date": "2025-06-09",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-277-6348"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "MD",
            "license": "P01777",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2034796",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "468004900",
            "state": "MD"
        }
    ],
    "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 10-1968",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Aberdeen, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.