Provider Demographics
NPI:1841355815
Name:WALMART INC.
Entity type:Organization
Organization Name:WALMART INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANONIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-277-6348
Mailing Address - Street 1:100 N 6TH ST
Mailing Address - Street 2:#900A
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-1505
Mailing Address - Country:US
Mailing Address - Phone:479-277-1242
Mailing Address - Fax:
Practice Address - Street 1:108 N APPLE BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-8679
Practice Address - Country:US
Practice Address - Phone:509-682-4634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WACF000589363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60310401Medicaid
WA6031041DMEMedicaid
2109030OtherPK
WA6031041Medicaid
WA60310401Medicaid