NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as Walmart Pharmacy 10-3453

  • Community/Retail Pharmacy
  • Wyoming, MI
National Provider Identifier
1942612874
Registry record updated Jun 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
5301010472 Issued in MI
Legal business name
WAL-MART STORES EAST LP
Doing business as
Walmart Pharmacy 10-3453
Practice address
355 54TH St SW
Wyoming, MI 49548-5614
Phone
(616) 552-6226
NPI assigned
May 27, 2014
Last updated
Jun 9, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 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 5301010472 MI Primary

Addresses

Primary practice location

355 54TH St SW
Wyoming, MI 49548-5614

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1242

Other identifiers 2

IdentifierTypeStateIssuer
2146177OtherPK
1053723841MedicaidMI

Other names 1

  • Walmart Pharmacy 10-3453 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 MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140213000098 MI Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment
O20150417001867 MI DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Wyominig, MI

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2097536Walmart Pharmacy 10-3453355 54TH Street SW, Wyoming, MI 49548Certificate of waiverJun 17, 2027

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 20

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 20

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": "1401148800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749427200000",
    "number": "1942612874",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "355 54TH ST SW",
            "city": "WYOMING",
            "state": "MI",
            "postal_code": "495485614",
            "telephone_number": "616-552-6226"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-27",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MI",
            "license": "5301010472",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2146177",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1053723841",
            "state": "MI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "2.16.840.1.113883.3.667.2",
            "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 10-3453",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wyoming, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 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.