NPIMap

Organization Active NPI

Wal-Mart Stores East LP

  • Community/Retail Pharmacy
  • Macedon, NY
National Provider Identifier
1720206469
Registry record updated Jul 8, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
28361 Issued in NY
Legal business name
WAL-MART STORES EAST LP
Practice address
425 Route 31
Macedon, NY 14502-9108
Phone
(315) 986-7153
NPI assigned
Apr 20, 2007
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Kimberly Canonic
Title
Senior Director Enrollment
Phone
(480) 853-0515

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930073421 NY DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Macedon, NY
O20140416001090 NY Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment

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

Locations

425 State Route 31
Macedon, NY 14502
Phone (315) 986-1584

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 28361 NY Primary

Addresses

NPPES NPI Registry

Primary practice location

425 Route 31
Macedon, NY 14502-9108

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers 2

NPPES NPI Registry
IdentifierTypeStateIssuer
02892006MedicaidNY
2069070OtherPK

Other names 1

NPPES NPI Registry
  • WAL-MART PHARMACY 10-3842 Doing business as

Electronic endpoints 1

NPPES NPI Registry
TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jul 8, 2025.

{
    "created_epoch": "1177027200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751932800000",
    "number": "1720206469",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 ROUTE 31",
            "city": "MACEDON",
            "state": "NY",
            "postal_code": "145029108",
            "telephone_number": "315-986-7153"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-20",
        "last_updated": "2025-07-08",
        "certification_date": "2025-07-08",
        "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": "NY",
            "license": "28361",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02892006",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2069070",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "N",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "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 10-3842",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Macedon, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.