NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as WalMart Pharmacy 10-4456

  • Community/Retail Pharmacy
  • Somerdale, NJ
National Provider Identifier
1295042257
Registry record updated Jul 10, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
28RS00708700 Issued in NJ
Legal business name
WAL-MART STORES EAST LP
Doing business as
WalMart Pharmacy 10-4456
Practice address
1 Coopertowne Blvd
Somerdale, NJ 08083-1433
Phone
(856) 545-9074
NPI assigned
Sep 10, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 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) 853-0515

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 28RS00708700 NJ Primary

Addresses

Primary practice location

1 Coopertowne Blvd
Somerdale, NJ 08083-1433

Mailing address

702 SW 8TH St
Bentonville, AR 72716-6209
Phone (479) 277-1238

Other identifiers 1

IdentifierTypeStateIssuer
2126720OtherPK

Other names 1

  • WalMart Pharmacy 10-4456 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 NJ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110120000242 NJ DME Supplier - Pharmacy 6204749997 Practice locations: Somerdale, NJ
O20130830000234 NJ Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment

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.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Wal-Mart Stores East LP1 Coopertowne Blvd, Somerdale, NJ 08083-1433(856) 545-9074 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 Jul 1, 2014

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,654 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 East Inc

    dba Sams Pharmacy 10-4851

    • Community/Retail Pharmacy
    • Clarksville, IN
    • NPI 1740207117

    Member Of

    NPD member
  • Walmart Inc.

    dba WalMart Pharmacy 10-4208

    • Community/Retail Pharmacy
    • Salt Lake City, UT
    • NPI 1326396300

    Member Of

    NPD member

Locations

1 Coopertowne Blvd
Somerdale, NJ 08083
Phone (856) 545-9057

NPI Registry JSON

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

{
    "created_epoch": "1284076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752105600000",
    "number": "1295042257",
    "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": "727166209",
            "telephone_number": "479-277-1238",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 COOPERTOWNE BLVD",
            "city": "SOMERDALE",
            "state": "NJ",
            "postal_code": "080831433",
            "telephone_number": "856-545-9074"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-09-10",
        "last_updated": "2025-07-10",
        "certification_date": "2025-07-10",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "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": "NJ",
            "license": "28RS00708700",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2126720",
            "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 10-4456",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Somerdale, NJ

Sources for this page

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