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	3336C0003X	Community/Retail Pharmacy	PDO.1680000018	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2138194	OTHER		PK

General Provider Information

NPI Number	:	1790029494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALMART INC.

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-204-0709
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	1622 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-4521
Country	:	US
Telephone Number	:	719-244-9572
Fax Number	:

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-277-6348

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	06/05/2025

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Directions to “WALMART INC. ” Practice Location

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