NPIMap

Organization Active NPI

Wal-Mart Puerto Rico Inc

Doing business as Walmart Pharmacy 10-5802

  • Community/Retail Pharmacy
  • Canovanas, PR
National Provider Identifier
1194988709
Registry record updated Jul 17, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
18-P-2535 Issued in PR
Legal business name
WAL-MART PUERTO RICO INC
Doing business as
Walmart Pharmacy 10-5802
Practice address
Plaza Canovanas Hwy 3 Int New RT 66
Canovanas, PR 00729
Phone
(787) 957-2715
NPI assigned
Jul 3, 2008
Last updated
Jul 17, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2026

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 18-P-2535 PR Primary

Addresses

Primary practice location

Plaza Canovanas Hwy 3 Int New RT 66
Canovanas, PR 00729

Mailing address

1 Customer Dr
Ms 0445
Bentonville, AR 72716-6209

Other identifiers 1

IdentifierTypeStateIssuer
2087885OtherPK

Other names 1

  • WALMART PHARMACY 10-5802 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 PR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130619000230 PR DME Supplier - PharmacyDME Supplier - Optician 1850508573 Practice locations: Canovanas, PR
O20140130001758 PR Part B Supplier - Mass Immunization (Roster Biller Only) 1850508573 29 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: San Juan, PR; Toa Baja, PR; Santa Isabel, PR; Ponce, PR; Mayaguez, PR; Manati, PR; Isabela, PR; Humacao, PR…

Other NPIs with the same Medicare PAC ID 19

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 19

Other NPIs on the same Medicare enrollment 29

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

View all 29

National Provider Directory

National Provider Directory
Tax ID family
Ability Network66 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.

  • Sams West Inc

    dba Sams Pharmacy 10-6254

    • Community/Retail Pharmacy
    • Maple Grove, MN
    • NPI 1184641581

    Member Of

    NPD member
  • Walmart Inc.

    dba Walmart Pharmacy 10-1588

    • Community/Retail Pharmacy
    • Victorville, CA
    • NPI 1043237456

    Member Of

    NPD member

NPI Registry JSON

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

{
    "created_epoch": "1215043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784246400000",
    "number": "1194988709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 CUSTOMER DR",
            "address_2": "MS 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727166209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "PLAZA CANOVANAS HWY 3 INT NEW RT 66",
            "city": "CANOVANAS",
            "state": "PR",
            "postal_code": "00729",
            "telephone_number": "787-957-2715"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART PUERTO RICO INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-03",
        "last_updated": "2026-07-17",
        "certification_date": "2026-07-17",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-277-6348"
    },
    "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": "PR",
            "license": "18-P-2535",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2087885",
            "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 10-5802",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALMART PHARMACY 10-5802",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canovanas, PR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.