NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as WalMart Pharmacy 10-4484

  • Community/Retail Pharmacy
  • Raleigh, NC
National Provider Identifier
1790085496
Registry record updated Aug 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
10888 Issued in NC
Legal business name
WAL-MART STORES EAST LP
Doing business as
WalMart Pharmacy 10-4484
Practice address
8000 Town Dr
Raleigh, NC 27616-2828
Phone
(919) 431-9632
NPI assigned
Oct 27, 2010
Last updated
Aug 6, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 6, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Community/Retail Pharmacy 3336C0003X 10888 NC Primary

Addresses

Primary practice location

8000 Town Dr
Raleigh, NC 27616-2828

Mailing address

702 SW 8TH St
Bentonville, AR 72716-6209

Other identifiers 2

IdentifierTypeStateIssuer
2127453OtherPK
0920616MedicaidNC

Other names 1

  • WalMart Pharmacy 10-4484 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 NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20111209000507 NC DME Supplier - PharmacyDME Supplier - Optician 6204749997 1 other NPI on this enrollment
Practice locations: Raleigh, NC
O20130724000619 NC Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,654 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 10-8256

    • Community/Retail Pharmacy
    • Knoxville, TN
    • NPI 1265459465

    Member Of

    NPD member
  • Walmart Inc.

    dba Walmart Pharmacy 10-1588

    • Community/Retail Pharmacy
    • Victorville, CA
    • NPI 1043237456

    Member Of

    NPD member

NPI Registry JSON

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

{
    "created_epoch": "1288137600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1754438400000",
    "number": "1790085496",
    "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": "727166209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8000 TOWN DR",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276162828",
            "telephone_number": "919-431-9632"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-27",
        "last_updated": "2025-08-06",
        "certification_date": "2025-08-06",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NC",
            "license": "10888",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2127453",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0920616",
            "state": "NC"
        }
    ],
    "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 10-4484",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Raleigh, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 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.