Healthcare Provider Details

I. General information

NPI: 1689551004
Provider Name (Legal Business Name): WAL-MART STORES TEXAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 MCKINNEY ST
MELISSA TX
75454-9957
US

IV. Provider business mailing address

1 CUSTOMER DR
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 945-234-6959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 480-853-0515