Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Greece, NY
NPI 1629339189 · NPPES record last updated Jun 16, 2025
Key facts
- NPI
- 1629339189
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 031432 (NY)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 3800 Dewey Ave
Greece, NY 14616-2529 - Phone
- (585) 957-7389
- NPI assigned
- May 31, 2012
- 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 NY
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130913000461 | NY | DME Supplier - Pharmacy |
6204749997 | Practice locations: Greece, NY |
| O20140416001090 | NY | 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 | |||
| Community/Retail Pharmacy | 3336C0003X | 031432 | NY | Yes |
Addresses
Primary practice location
3800 Dewey Ave
Greece, NY 14616-2529
Mailing address
702 SW 8TH St
Bentonville, AR 72716-6209
Phone (479) 277-1242
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 03912672 | Medicaid | NY | |
| 2135548 | Other | PK |
Other names
- WalMart Pharmacy 10-5282
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 Greece, NY
- TC Greece Pediatric Dentistry PLLC
- Tops Markets LLC
- Ashellee E Toweh
- Colleen Marie Varney
- Wal-Mart Stores East , LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East, LP
- Christine Elizabeth Wallace
- Debra Wallace
- Janet M Williams
All providers in Greece, NY · Community/Retail Pharmacy in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 16, 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.