NPIMap

Organization Active NPI

Wal-Mart Stores East , LP

Doing business as Walmart Pharmacy 10-6932

  • Pharmacy
  • Shreveport, LA
National Provider Identifier
1396117735
Registry record updated Jun 10, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
PHY.007230-RC Issued in LA
Legal business name
WAL-MART STORES EAST , LP
Doing business as
Walmart Pharmacy 10-6932
Practice address
4701 Northport Blvd
Shreveport, LA 71107
Phone
(318) 929-3071
NPI assigned
Oct 26, 2015
Last updated
Jun 10, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 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) 277-6348

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X PHY.007230-RC LA Primary
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

4701 Northport Blvd
Shreveport, LA 71107

Mailing address

702 SW 8TH St
Mailstop 0445
Bentonville, AR 72716-0445
Phone (479) 204-8550

Other identifiers 2

IdentifierTypeStateIssuer
2155385OtherPK
2204173MedicaidLA

Other names 1

  • Walmart Pharmacy 10-6932 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 LA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140613001865 LA Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment
O20160222002076 LA DME Supplier - Pharmacy 6204749997 Practice locations: Shreveport, LA

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.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2101858Walmart Pharmacy 10-69324701 Northport Blvd, Shreveport, LA 71107Certificate of waiverSep 10, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-69324701 Northport Blvd, Shreveport, LA 71107-2539(318) 929-3071 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 10-8256

    • Community/Retail Pharmacy
    • Knoxville, TN
    • NPI 1265459465

    Member Of

    NPD member
  • Walmart Inc.

    dba Walmart Pharmacy 10-1588

    • Community/Retail Pharmacy
    • Victorville, CA
    • NPI 1043237456

    Member Of

    NPD member

Locations

4701 Northport Blvd
Shreveport, LA 71107
Phone (318) 309-9561

NPI Registry JSON

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

{
    "created_epoch": "1445817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749513600000",
    "number": "1396117735",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "address_2": "MAILSTOP 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-204-8550"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4701 NORTHPORT BLVD",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "71107",
            "telephone_number": "318-929-3071"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST , LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-26",
        "last_updated": "2025-06-10",
        "certification_date": "2025-06-10",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "LA",
            "license": "PHY.007230-RC",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2155385",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2204173",
            "state": "LA"
        }
    ],
    "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 10-6932",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shreveport, LA

Sources for this page

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