Wal-Mart Stores East LP
Organization Active NPI Community/Retail Pharmacy · Shelbyville, TN
NPI 1891712089 · NPPES record last updated Jun 3, 2025
Key facts
- NPI
- 1891712089
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 2317 (TN)
- Legal business name
- WAL-MART STORES EAST LP
- Practice address
- 1880 N Main St
Shelbyville, TN 37160-2018 - Phone
- (931) 685-1099
- Fax
- (931) 685-1097
- NPI assigned
- Jul 16, 2006
- 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
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D2140111 | Walmart Pharmacy 10-0656 | Certificate of waiver | Nov 13, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930098045 | TN | DME Supplier - Pharmacy |
6204749997 | Practice locations: Shelbyville, TN |
| O20130808000651 | TN | Part B Supplier - Mass Immunization (Roster Biller Only) | 6204749997 | This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Ability Network
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 2317 | TN | Yes |
Addresses
Primary practice location
1880 N Main St
Shelbyville, TN 37160-2018
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-8550
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1454031 | Medicaid | TN | |
| 2091392 | Other | PK |
Other names
- WALMART PHARMACY 10-0656
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
Other providers in Shelbyville, TN
- Vanderbilt Bedford Hospital, LLC
- Karen Beth Venable
- Miguel Angel Villegas
- Tonya May Villegas
- Maria Voigts
- Wal-Mart Stores East, LP
- Walgreen Co
- Walgreen Co
- Walking Horse Emergency Physicians LLC
- Walou Inc.
All providers in Shelbyville, TN · Community/Retail Pharmacy in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 3, 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.