MEDICARE: WALMART INC.

Medicare Provider Information

Scope of Practice

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	PH02078	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2052111	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740409275
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	:	6570 E LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-7044
Country	:	US
Telephone Number	:	702-437-2554
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	06/16/2025

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