NPIMap

Wal-Mart Stores East LP

Organization Active NPI Community/Retail Pharmacy · Belle Vernon, PA

NPI 1477571230 · NPPES record last updated May 30, 2025

Key facts

NPI
1477571230
Entity type
Organization (NPI type 2)
Primary specialty
Community/Retail Pharmacy 3336C0003X
License
PP415212L (PA)
Legal business name
WAL-MART STORES EAST LP
Practice address
100 Sara Way/ Rostraver Squatre
Belle Vernon, PA 15012-1963
Phone
(724) 929-2437
NPI assigned
Jul 18, 2006
Organization subpart
No

Authorized official

Name
Kimberly Canonic
Title
Senior Director, Enrollment
Phone
(480) 277-6348

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Member of 2

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in PA

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20100930022557 PA DME Supplier - Pharmacy
DME Supplier - Optician		 6204749997 Practice locations: Belle Vernon, PA
O20130924000644 PA 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 (4,651 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X PP415212L PA Yes

Addresses

Primary practice location

100 Sara Way/ Rostraver Squatre
Belle Vernon, PA 15012-1963

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers

IdentifierTypeStateIssuer
1007455310119MedicaidPA
2083293OtherPK

Other names

  • WAL-MART PHARMACY 10-2420 Doing business as

Electronic endpoints

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 30, 2025.

{
    "created_epoch": "1153180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748563200000",
    "number": "1477571230",
    "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": "100 SARA WAY/ ROSTRAVER SQUATRE",
            "city": "BELLE VERNON",
            "state": "PA",
            "postal_code": "150121963",
            "telephone_number": "724-929-2437"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-18",
        "last_updated": "2025-05-30",
        "certification_date": "2025-05-30",
        "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": "PA",
            "license": "PP415212L",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1007455310119",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2083293",
            "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 10-2420",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Belle Vernon, PA

All providers in Belle Vernon, PA · Community/Retail Pharmacy in Pennsylvania

Sources for this page

Verify at the official NPI Registry.