MEDICARE: WALMART INC.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	0001255CS	OR

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	2078272	OTHER	PK

NPI Number	:	1134146277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALMART INC.

Provider Business Mailing Address
First Line	:	702 SW 8TH STREET
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11619 ISLAND AVE
Second Line	:
City	:	ISLAND CITY
State	:	OR
Zip	:	97850-8459
Country	:	US
Telephone Number	:	541-963-5460
Fax Number	:

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-853-0515

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	06/12/2025

11619 ISLAND AVE
LA GRANDE, OR
97850-8459

Practice Phone: 541-633-9720
Practice Fax:

11619 ISLAND AVE
ISLAND CITY, OR
97850-8459