NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as Wal-Mart Pharmacy 10-3621

  • Community/Retail Pharmacy
  • Chamblee, GA
National Provider Identifier
1659436863
Registry record updated Jul 2, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHRE009108 Issued in GA
Legal business name
WAL-MART STORES EAST LP
Doing business as
Wal-Mart Pharmacy 10-3621
Practice address
1871 Chamblee Tucker Rd
Chamblee, GA 30341-2737
Phone
(770) 455-4699
NPI assigned
Dec 27, 2006
Last updated
Jul 2, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 2, 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) 853-0515

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X PHRE009108 GA Primary

Addresses

Primary practice location

1871 Chamblee Tucker Rd
Chamblee, GA 30341-2737

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
623765613AMedicaidGA
2016460OtherPK

Other names 1

  • WAL-MART PHARMACY 10-3621 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
O20100930011693 GA DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Chamblee, 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.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Wal-Mart Stores East , LP1871 Chamblee Tucker Rd, Chamblee, GA 30341-2737(770) 455-4699 Epoetin|Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Prosthetic Lenses: Conventional Eyeglasses|Enteral Nutrients|Surgical Dressings Does not accept assignmentParticipating since Jul 1, 2014

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,659 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

    • Community/Retail Pharmacy
    • San Antonio, TX
    • NPI 1932126059

    Member Of

    NPD member
  • Walmart Inc.

    dba Walmart Pharmacy 10-2050

    • Community/Retail Pharmacy
    • Henderson, NV
    • NPI 1043237142

    Member Of

    NPD member

Locations

1871 Chamblee Tucker Rd
Chamblee, GA 30341
Phone (770) 455-4699

Practitioners & affiliated clinicians

Practitioners 4

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": "1167177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751414400000",
    "number": "1659436863",
    "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": "479-277-1242"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1871 CHAMBLEE TUCKER RD",
            "city": "CHAMBLEE",
            "state": "GA",
            "postal_code": "303412737",
            "telephone_number": "770-455-4699"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-27",
        "last_updated": "2025-07-02",
        "certification_date": "2025-07-02",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHRE009108",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "623765613A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2016460",
            "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 10-3621",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chamblee, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 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.