NPIMap

Organization Active NPI

Walmart Inc.

  • Community/Retail Pharmacy
  • Andover, MN
National Provider Identifier
1194158618
Registry record updated Jun 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
264238 Issued in MN
Legal business name
WALMART INC.
Practice address
1851 Bunker Lake Blvd NW
Andover, MN 55304-4010
Phone
(763) 354-5720
Fax
(763) 354-5714
NPI assigned
Aug 20, 2013
Organization subpart
No

Authorized official

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

Corporate family (same tax ID) 24

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

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
24D2097790Walmart Pharmacy 10-19991851 Bunker Lake Blvd NW, Andover, MN 55304Certificate of waiverJun 23, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-19991851 Bunker Lake Blvd NW, Andover, MN 55304-4010(763) 354-5720 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|Prosthetic Lenses: Conventional Eyeglasses|Enteral Nutrients|Surgical Dressings Does not accept assignmentParticipating since Jan 1, 2019

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Medicare enrollment records 2

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20130816000325 MN Part B Supplier - Mass Immunization (Roster Biller Only) 4385556745 This NPI is an additional NPI on the enrollment
O20131203000685 MN DME Supplier - PharmacyDME Supplier - Optician 4385556745 Practice locations: Andover, MN

National Provider Directory

National Provider Directory
Tax ID family
Ability Network (2,173 organizations share this tax ID)

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 264238 MN Primary

Addresses

NPPES NPI Registry

Primary practice location

1851 Bunker Lake Blvd NW
Andover, MN 55304-4010

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-8550

Other identifiers 1

NPPES NPI Registry
IdentifierTypeStateIssuer
2141820OtherPK

Other names 1

NPPES NPI Registry
  • WalMart Pharmacy 10-1999 Doing business as

Electronic endpoints 1

NPPES NPI Registry
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 format, last updated by the provider on Jun 6, 2025.

{
    "created_epoch": "1376956800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749168000000",
    "number": "1194158618",
    "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": "479-204-8550",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1851 BUNKER LAKE BLVD NW",
            "city": "ANDOVER",
            "state": "MN",
            "postal_code": "553044010",
            "telephone_number": "763-354-5720",
            "fax_number": "763-354-5714"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALMART INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-08-20",
        "last_updated": "2025-06-06",
        "certification_date": "2025-06-06",
        "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": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "264238",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2141820",
            "state": null
        }
    ],
    "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 10-1999",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Andover, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 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.