Wal-Mart Stores East LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PHRE007922 Issued in GA

Legal business name

WAL-MART STORES EAST LP

Practice address

4725 Ashford Dunwoody Rd
Atlanta, GA 30338-5561

Phone

(770) 395-7946

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

• WAL-MART PHARMACY 10-2360 Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

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

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

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748822400000",
    "number": "1376560607",
    "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": "4725 ASHFORD DUNWOODY RD",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303385561",
            "telephone_number": "770-395-7946"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-06-02",
        "certification_date": "2025-06-02",
        "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": "GA",
            "license": "PHRE007922",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00681304A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2019168",
            "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": "WAL-MART PHARMACY 10-2360",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Hans Douglas Wakeman, D.C.
• Lucas Grant Wakeman, LMT
• Wal-Mart Stores East , LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP

• All providers in Atlanta, GA
• Community/Retail Pharmacy in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2025; 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.