Wal-Mart Stores East , LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

27473 Issued in OK

Legal business name

WAL-MART STORES EAST , LP

Doing business as

Walmart Pharmacy 10-4655

Practice address

1300 E Albany St
Broken Arrow, OK 74012-8951

Phone

(918) 505-6246

Fax

(918) 505-6245

NPI assigned

Nov 5, 2015

Last updated

Jun 10, 2025By the provider in NPPES

Organization subpart

No

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 3

Addresses

Other identifiers 2

Other names 1

• Walmart Pharmacy 10-4655 Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Medicare medical equipment & supply locations

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

Practitioners 2

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.

• Madison Chaise Garrett, PHARMD

  • Pharmacist
  • Broken Arrow, OK
  • NPI 1396489381
  NPD (past)
• Tri Minh Le, RPH, PHARM.D

  • Pharmacist
  • Broken Arrow, OK
  • NPI 1184226326
  NPD (past)

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

{
    "created_epoch": "1446681600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749513600000",
    "number": "1881067346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "address_2": "MAILSTOP 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-204-1258",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 E ALBANY ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740128951",
            "telephone_number": "918-505-6246",
            "fax_number": "918-505-6245"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST , LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-05",
        "last_updated": "2025-06-10",
        "certification_date": "2025-06-10",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "27473",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200625230A",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2155605",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.22.16.840.1.113883.3.667.2",
            "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 10-4655",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jeff W Wade, PHARMD
• Timothy Allen Wagner, D.C.
• Lewis Waits, PHARM.D
• Wal-Mart Stores East , LP (Walmart Pharmacy 10-6942)
• Wal-Mart Stores East , LP (Walmart Vision Center 30-3295)
• Wal-Mart Stores East , LP (Walmart Pharmacy 10-0472)
• Wal-Mart Stores East LP (Walmart Pharmacy 10-0472)
• Wal-Mart Stores East LP (Wal-Mart Pharmacy 10-3295)
• Wal-Mart Stores East LP (Wal-Mart Pharmacy 10-3508)
• Wal-Mart Stores East LP (WalMart Pharmacy 10-4637)

• Community/Retail Pharmacy in Broken Arrow, OK
• Providers in Broken Arrow, OK by specialty
• Community/Retail Pharmacy in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 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.