Wal-Mart Stores East LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

55-5459 Issued in OK

Legal business name

WAL-MART STORES EAST LP

Practice address

2705 W Broadway Ave
Sulphur, OK 73086-6508

Phone

(580) 622-6181

NPI assigned

Jul 16, 2006

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 3

Addresses

Other identifiers 2

Other names 1

• WALMART PHARMACY 10-0225 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.

CLIA laboratory certificates

Medicare medical equipment & supply locations

Member of 2

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

• Sams East Inc

  • Community/Retail Pharmacy
  • Hudson, NH
  • NPI 1982621009

  Member Of

  NPD member
• Walmart Inc.

  • Community/Retail Pharmacy
  • Pearl City, HI
  • NPI 1174541650

  Member Of

  NPD member

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Stefan Jones

  • Pharmacist
  • Sulphur, OK
  • NPI 1649870106
  NPD (past)
• Mickey Morrow, DPH

  • Pharmacist
  • Sulphur, OK
  • NPI 1760135404
  NPD (past)
• Luke Nguyen

  • Pharmacist
  • Sulphur, OK
  • NPI 1336859370
  NPD (past)
• Neha Susan Abraham

  • Pharmacist
  • Hayward, CA
  • NPI 1699375279
  NPD (past)

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

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748476800000",
    "number": "1316964430",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2705 W BROADWAY AVE",
            "city": "SULPHUR",
            "state": "OK",
            "postal_code": "730866508",
            "telephone_number": "580-622-6181"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-05-29",
        "certification_date": "2025-05-29",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "55-5459",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2074077",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100239530A",
            "state": "OK"
        }
    ],
    "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 10-0225",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALMART PHARMACY 10-0225",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tessa Todd
• Teresa Truelock
• Robert Thomas Vallandingham, D.C.
• Darsha Marie Venegas
• Jami Dawn Wages
• Amy Lynn Walker, PRSS
• Deanna Watterson
• West Chiropractic PC
• Darci Nicole White, FSP
• Randal A Williams, M.D.

• Community/Retail Pharmacy in Sulphur, OK
• Providers in Sulphur, 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 May 29, 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.