Wal-Mart Stores East , LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2-7368 Issued in OK

Legal business name

WAL-MART STORES EAST , LP

Doing business as

Walmart Pharmacy 10-4585

Practice address

11551 N 129TH East Ave
Owasso, OK 74055-7446

Phone

(918) 371-3585

Fax

(918) 371-3733

NPI assigned

Jun 4, 2015

Last updated

Apr 10, 2026By the provider in NPPES

Organization subpart

No

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

Addresses

Other names 1

• Walmart Pharmacy 10-4585 Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

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

Medicare medical equipment & supply locations

Member of 2

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

• Sams East Inc

  dba Sams Pharmacy 10-8186

  • Community/Retail Pharmacy
  • Scarborough, ME
  • NPI 1144483520

  Member Of

  NPD member
• Walmart Inc.

  dba Walmart Pharmacy 10-2422

  • Community/Retail Pharmacy
  • Saint Helens, OR
  • NPI 1962429019

  Member Of

  NPD member

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Grace Wolfendale, PHARMD

  • Pharmacist
  • Owasso, OK
  • NPI 1568067320
  NPD (past)

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

{
    "created_epoch": "1433376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1775779200000",
    "number": "1275913352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 CUSTOMER DR # MS 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11551 N 129TH EAST AVE",
            "city": "OWASSO",
            "state": "OK",
            "postal_code": "740557446",
            "telephone_number": "918-371-3585",
            "fax_number": "918-371-3733"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST , LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-04",
        "last_updated": "2026-04-10",
        "certification_date": "2026-04-10",
        "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": "OK",
            "license": "2-7368",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.22.16.840.1.113883.3.667.2",
            "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 10-4585",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Robert Rendell Vincent, OD
• Kyle Volz, PHARMACIST
• Donald Von Borstel, D.O.
• Jayson Dean Voto, D.D.S.
• Amanda Wagnon
• Wal-Mart Stores East LP (Walmart Pharmacy 10-0168)
• Wal-Mart Stores East LP (WalMart Pharmacy 10-5840)
• Walgreen Co (Walgreens #02361)
• Walgreen Co (Walgreens #15762)
• Chelsea Ryan Walker, APRN-CPNP

• Community/Retail Pharmacy in Owasso, OK
• Providers in Owasso, OK by specialty
• Community/Retail Pharmacy in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2026; 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.