NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as Wal-Mart Pharmacy 10-1891

  • Community/Retail Pharmacy
  • Manchester, CT
National Provider Identifier
1417974791
Registry record updated Jun 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PCY0001455 Issued in CT
Legal business name
WAL-MART STORES EAST LP
Doing business as
Wal-Mart Pharmacy 10-1891
Practice address
420 Buckland Hills Dr
Manchester, CT 06042-8755
Phone
(860) 644-5105
NPI assigned
Jul 16, 2006
Last updated
Jun 12, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X NU
Community/Retail Pharmacy 3336C0003X PCY0001455 CT Primary

Addresses

Primary practice location

420 Buckland Hills Dr
Manchester, CT 06042-8755

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers 3

IdentifierTypeStateIssuer
940004129161MedicaidCT
2000248OtherPK
004129161MedicaidCT

Other names 1

  • WAL-MART PHARMACY 10-1891 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 CT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930080032 CT DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Manchester, CT
O20131226000547 CT Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 33 other NPIs on this enrollment
Practice locations: New Milford, CT; North Windham, CT; Norwalk, CT; Norwich, CT; Old Saybrook, CT; Putnam, CT; Rocky Hill, CT; Shelton, CT…

Other NPIs on the same Medicare enrollment 32

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 32

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

420 Buckland Hills Dr
#10
Manchester, CT 06042
Phone (860) 644-5105

NPI Registry JSON

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

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749686400000",
    "number": "1417974791",
    "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": "420 BUCKLAND HILLS DR",
            "city": "MANCHESTER",
            "state": "CT",
            "postal_code": "060428755",
            "telephone_number": "860-644-5105"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-06-12",
        "certification_date": "2025-06-12",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CT",
            "license": "PCY0001455",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "940004129161",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2000248",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004129161",
            "state": "CT"
        }
    ],
    "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 10-1891",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manchester, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 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.