Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Newport News, VA
NPI 1386988715 · NPPES record last updated Jun 6, 2025
Key facts
- NPI
- 1386988715
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 0201004499 (VA)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 11214 Jefferson Ave
Newport News, VA 23601-2207 - Phone
- (757) 327-7478
- NPI assigned
- Nov 26, 2012
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 277-6348
Corporate family (same tax ID) 24
Member of 2
Practitioners 3
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 49D2116743 | Wal-Mart Stores East, LP | Certificate of waiver | Jul 31, 2026 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Wal-Mart Stores East LP |
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 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in VA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130927000583 | VA | DME Supplier - Pharmacy | 6204749997 | Practice locations: Newport News, VA |
| O20140606001173 | VA | Part B Supplier - Mass Immunization (Roster Biller Only) | 6204749997 | This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Ability Network
Locations
11214 Jefferson Ave
Newport News, VA 23601
Phone (757) 327-7473
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 0201004499 | VA | Yes |
Addresses
Primary practice location
11214 Jefferson Ave
Newport News, VA 23601-2207
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-0709
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2138062 | Other | PK | |
| 1386988715 | Medicaid | VA | |
| 1386988715 DME | Medicaid | VA |
Other names
- Wal-Mart Pharmacy 10-3157
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
Other providers in Newport News, VA
- Sheetal A Wagle
- John Adrian Waite
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East, LP.
- Tyree Vincent-Dwayne Waldon
- Amy Sue Waldron
- Eric G Waldrop
- Walgreen Co
All providers in Newport News, VA · Community/Retail Pharmacy in Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 6, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.