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Wal-Mart Stores East LP

Organization Active NPI Community/Retail Pharmacy · Jeffersontown, KY

NPI 1245257575 · NPPES record last updated Jun 12, 2025

Key facts

NPI
1245257575
Entity type
Organization (NPI type 2)
Primary specialty
Community/Retail Pharmacy 3336C0003X
License
P06888 (KY)
Legal business name
WAL-MART STORES EAST LP
Practice address
3800 Ruckriegel Pkwy
Jeffersontown, KY 40299-3958
Phone
(502) 266-5022
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) 24

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

Member of 2

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

Laboratory certificates & supplier records

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D2138745Walmart Pharmacy 10-5183
3800 Ruckriegel Pkwy, Jeffersontown, KY 40299		Certificate of waiverOct 23, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmary 10-5183
3800 Ruckriegel Pkwy, Jeffersontown, KY 40299-3958 · (502) 266-5022		 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
Participating since Jul 1, 2014

Medicare participation

Medicare fee-for-service enrollment
Enrolled (3 enrollments) in KY

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20100930034614 KY DME Supplier - Pharmacy 6204749997 Practice locations: Jeffersontown, KY
O20130807000885 KY Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment
O20220901001467 KY Part B Supplier - Independent Clinical Laboratory 6204749997 This NPI is an additional NPI on the enrollment

National Provider Directory

Tax ID family
Ability Network (4,651 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X P06888 KY Yes

Addresses

Primary practice location

3800 Ruckriegel Pkwy
Jeffersontown, KY 40299-3958

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers

IdentifierTypeStateIssuer
2034097OtherPK
5400696000MedicaidKY

Other names

  • WALMART PHARMACY 10-5183 Doing business as

Electronic endpoints

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

Other providers in Jeffersontown, KY

All providers in Jeffersontown, KY · Community/Retail Pharmacy in Kentucky

Sources for this page

Verify at the official NPI Registry.