NPIMap

Organization Active NPI

Wal-Mart Stores East LP

  • Community/Retail Pharmacy
  • Phenix City, AL
National Provider Identifier
1629448451
Registry record updated Jun 10, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
114567 Issued in AL
Legal business name
WAL-MART STORES EAST LP
Practice address
3864 US Highway 80 W
Phenix City, AL 36870-6526
Phone
(334) 408-6068
Fax
(334) 408-6067
NPI assigned
Oct 6, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 10, 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 114567 AL Primary

Addresses

Primary practice location

3864 US Highway 80 W
Phenix City, AL 36870-6526

Mailing address

702 SW 8TH St
Mailstop 0445
Bentonville, AR 72716-0445
Phone (479) 277-1242

Other identifiers 3

IdentifierTypeStateIssuer
187881MedicaidAL
2155149OtherPK
1629448451MedicaidAL

Other names 1

  • Walmart Pharmacy 10-5903 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 AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130807000603 AL Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment
O20160316001812 AL DME Supplier - Pharmacy 6204749997 Practice locations: Phenix City, AL

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
01D2158439Walmart Pharmacy 10-59033864 US Highway 80 W, Phenix City, AL 36870Certificate of waiverNov 27, 2026

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Wal-Mart Stores East LP3864 US Highway 80 W, Phenix City, AL 36870-6526(334) 408-6068 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 Network4,651 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.

Locations

3864 US Highway 80 W
Phenix City, AL 36870
Phone (334) 408-6068

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1444089600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749513600000",
    "number": "1629448451",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "address_2": "MAILSTOP 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-277-1242",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3864 US HIGHWAY 80 W",
            "city": "PHENIX CITY",
            "state": "AL",
            "postal_code": "368706526",
            "telephone_number": "334-408-6068",
            "fax_number": "334-408-6067"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-06",
        "last_updated": "2025-06-10",
        "certification_date": "2025-06-10",
        "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": "AL",
            "license": "114567",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "187881",
            "state": "AL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2155149",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1629448451",
            "state": "AL"
        }
    ],
    "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 10-5903",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Phenix City, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 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.