NPIMap

Organization Active NPI

Walmart Inc

  • Pharmacy
  • Warrenton, OR
National Provider Identifier
1710489406
Registry record updated Jun 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
RP-0003387 Issued in OR
Legal business name
WALMART INC
Practice address
1791 Ensign Lane SE
Warrenton, OR 97146-7339
Phone
(503) 861-0644
Fax
(503) 861-0897
NPI assigned
Mar 8, 2018
Last updated
Jun 12, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X RP-0003387 OR Primary
Community/Retail Pharmacy 3336C0003X NU

Addresses

Primary practice location

1791 Ensign Lane SE
Warrenton, OR 97146-7339

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
500745490MedicaidOR
2103875MedicaidWA
2176573OtherPK

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 OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20151105000564 OR Part B Supplier - Mass Immunization (Roster Biller Only) 4385556745 46 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: McMinnville, OR; Milwaukie, OR; Medford, OR; Newport, OR; Ontario, OR; Pendleton, OR; Portland, OR; Redmond, OR…
O20180817001917 OR DME Supplier - Pharmacy 4385556745 Practice locations: Warrenton, OR

Other NPIs on the same Medicare enrollment 44

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 44

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
Walmart Pharmacy 10-58611791 SE Ensign LN, Warrenton, OR 97146-7410(503) 861-0644 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)|Enteral Nutrients|Surgical Dressings Does not accept assignmentParticipating since Jan 1, 2019

National Provider Directory

National Provider Directory
Tax ID family
Ability Network2,173 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

Locations

1791 SE Ensign Ln
Warrenton, OR 97146
Phone (503) 861-0146

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": "1520467200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749686400000",
    "number": "1710489406",
    "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",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1791 ENSIGN LANE SE",
            "city": "WARRENTON",
            "state": "OR",
            "postal_code": "971467339",
            "telephone_number": "503-861-0644",
            "fax_number": "503-861-0897"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALMART INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-03-08",
        "last_updated": "2025-06-12",
        "certification_date": "2025-06-12",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "OR",
            "license": "RP-0003387",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500745490",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2103875",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2176573",
            "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": []
}

Other providers in Warrenton, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 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.