Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Mayodan, NC
NPI 1528085768 · NPPES record last updated Jun 19, 2025
Key facts
- NPI
- 1528085768
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 09218 (NC)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 6711 NC Highway 135
Mayodan, NC 27027-8487 - Phone
- (336) 548-2737
- NPI assigned
- Jul 16, 2006
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 853-0515
Corporate family (same tax ID) 24
Member of 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930032140 | NC | DME Supplier - Pharmacy |
6204749997 | Practice locations: Mayodan, NC |
| O20130724000619 | NC | 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
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 09218 | NC | Yes |
Addresses
Primary practice location
6711 NC Highway 135
Mayodan, NC 27027-8487
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0775347 | Medicaid | NC | |
| 2065490 | Other | PK | |
| 9218 | Medicaid | NC |
Other names
- WAL-MART PHARMACY 10-3305
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 Mayodan, NC
- Therapeutic Alternatives Incorporated
- Christopher Tolliver
- Megan Linh Tran
- Unc Rockingham Health Care, Inc.
- Unc Rockingham Health Care, Inc.
- Wal-Mart Stores East, LP
All providers in Mayodan, NC · Community/Retail Pharmacy in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 19, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.