NPIMap

Organization Active NPI

Walmart Inc.

  • Community/Retail Pharmacy
  • Rexburg, ID
National Provider Identifier
1992722243
Registry record updated Jun 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
870RP Issued in ID
Legal business name
WALMART INC.
Doing business as
WALMART PHARMACY 10-1878
Practice address
1450 N 2ND E
Rexburg, ID 83440-5131
Phone
(208) 359-2814
Fax
(208) 359-2816
NPI assigned
Jul 16, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 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) 853-0515

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 870RP ID Primary

Addresses

Primary practice location

1450 N 2ND E
Rexburg, ID 83440-5131

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers 3

IdentifierTypeStateIssuer
002142100MedicaidID
2142100MedicaidID
2020961OtherPK

Other names 1

  • WALMART PHARMACY 10-1878 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 ID3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20100930083484 ID DME Supplier - PharmacyDME Supplier - Optician 4385556745 Practice locations: Rexburg, ID
O20130930000003 ID Part B Supplier - Mass Immunization (Roster Biller Only) 4385556745 25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rexburg, ID; Meridian, ID; Moscow, ID; Mountain Home, ID; Nampa, ID; Ponderay, ID; Post Falls, ID; Smelterville, ID…
O20221209001769 ID Part B Supplier - Independent Clinical Laboratory 4385556745 25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Moscow, ID; Mountain Home, ID; Meridian, ID; Nampa, ID; Ponderay, ID; Post Falls, ID; Rexburg, ID; Smelterville, ID…

Other NPIs on the same Medicare enrollment 25

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

View all 25

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
13D2149827Walmart Pharmacy #10-18781450 North 2ND East, Rexburg, ID 83440Certificate of waiverJun 11, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-18781450 N 2ND E, Rexburg, ID 83440-5131(208) 359-2814 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Prosthetic Lenses: Conventional Eyeglasses|Enteral Nutrients|Surgical Dressings Does not accept assignmentParticipating since Jan 1, 2019

National Provider Directory

National Provider Directory
Tax ID family
Ability Network2,173 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 12

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

Locations

530 N 2nd E
Rexburg, ID 83440
Phone (208) 359-2814

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749686400000",
    "number": "1992722243",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1450 N 2ND E",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834405131",
            "telephone_number": "208-359-2814",
            "fax_number": "208-359-2816"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALMART INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2025-06-12",
        "certification_date": "2025-06-12",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "870RP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002142100",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2142100",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2020961",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "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 10-1878",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rexburg, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 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.