NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as WalMart Pharmacy 10-5815

  • Community/Retail Pharmacy
  • Marietta, GA
National Provider Identifier
1487075222
Registry record updated Jun 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHRE009989 Issued in GA
Legal business name
WAL-MART STORES EAST LP
Doing business as
WalMart Pharmacy 10-5815
Practice address
2909 Austell Rd SW Ste 100
Marietta, GA 30008-6853
Phone
(770) 615-1381
NPI assigned
Dec 20, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 6, 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
Community/Retail Pharmacy 3336C0003X PHRE009989 GA Primary

Addresses

Primary practice location

2909 Austell Rd SW Ste 100
Marietta, GA 30008-6853

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-2500

Other identifiers 2

IdentifierTypeStateIssuer
003144413AMedicaidGA
2144022OtherPK

Other names 1

  • WalMart Pharmacy 10-5815 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 GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140328000729 GA DME Supplier - Pharmacy 6204749997 Practice locations: Marietta, GA
O20140910000822 GA Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 Receives reassigned benefits from 2 practitioners
This NPI is an additional NPI on the enrollment

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
11D2174704Walmart Pharmacy 10-58152909 Austell Rd SW, Marietta, GA 30008Certificate of waiverNov 5, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Wal-Mart Stores East LP2909 Austell Rd SW, Marietta, GA 30008-6853(770) 615-1381 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 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 10-4851

    • Community/Retail Pharmacy
    • Clarksville, IN
    • NPI 1740207117

    Member Of

    NPD member
  • Walmart Inc.

    dba WalMart Pharmacy 10-4208

    • Community/Retail Pharmacy
    • Salt Lake City, UT
    • NPI 1326396300

    Member Of

    NPD member

Locations

2909 Austell Rd SW
Ste 100
Marietta, GA 30008
Phone (770) 615-1381

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1387497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749168000000",
    "number": "1487075222",
    "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",
            "telephone_number": "479-277-2500",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2909 AUSTELL RD SW STE 100",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300086853",
            "telephone_number": "770-615-1381"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-20",
        "last_updated": "2025-06-06",
        "certification_date": "2025-06-06",
        "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": "PHRE009989",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003144413A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2144022",
            "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": "WalMart Pharmacy 10-5815",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marietta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 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.