Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Indianapolis, IN
NPI 1801209796 · NPPES record last updated Jun 9, 2025
Key facts
- NPI
- 1801209796
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 60006393A (IN)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 5555 Michigan Rd
Indianapolis, IN 46228-2219 - Phone
- (317) 287-0427
- Fax
- (317) 287-0428
- NPI assigned
- Jun 9, 2014
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 277-6348
Corporate family (same tax ID) 24
Member of 2
Practitioners 2
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D2124290 | Wal-Mart Stores East, LP Dba Wal-Mart | Certificate of waiver | Jan 11, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Walmart Pharmacy 10-4053 |
Epoetin|Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Canes and/or Crutches|Walkers|Ostomy Supplies|Prosthetic Lenses: Conventional Eyeglasses|Prosthetic Lenses: Conve… | Does not accept assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130824000051 | IN | Part B Supplier - Mass Immunization (Roster Biller Only) | 6204749997 | This NPI is an additional NPI on the enrollment |
| O20140905000804 | IN | DME Supplier - Pharmacy | 6204749997 | Practice locations: Indianapolis, IN |
National Provider Directory
- Tax ID family
- Ability Network
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Community/Retail Pharmacy | 3336C0003X | 60006393A | IN | Yes |
Addresses
Primary practice location
5555 Michigan Rd
Indianapolis, IN 46228-2219
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1242
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2146240 | Other | PK | |
| 201243120 A | Medicaid | IN |
Other names
- Walmart Pharmacy 10-4053
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
NPI Registry JSON
{
"created_epoch": "1402272000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1749427200000",
"number": "1801209796",
"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": "5555 MICHIGAN RD",
"city": "INDIANAPOLIS",
"state": "IN",
"postal_code": "462282219",
"telephone_number": "317-287-0427",
"fax_number": "317-287-0428"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "WAL-MART STORES EAST LP",
"organizational_subpart": "NO",
"enumeration_date": "2014-06-09",
"last_updated": "2025-06-09",
"certification_date": "2025-06-09",
"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": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "IN",
"license": "60006393A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2146240",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "201243120 A",
"state": "IN"
}
],
"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 10-4053",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Indianapolis, IN
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East LP
- Wal-Mart Stores East, LP
- Wal-Mart Stores East, LP
- Wal-Mart Stores East, LP
All providers in Indianapolis, IN · Community/Retail Pharmacy in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 9, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.