Provider Demographics
NPI:1730612425
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 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-258-2115
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:9400 RALSTON RD
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2004
Practice Address - Country:US
Practice Address - Phone:720-624-0333
Practice Address - Fax:720-624-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
COPDO.16800001473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1730612425Medicaid
2169358OtherPK