=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215956222
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART STORES TEXAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 W TRINITY MILLS RD
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75006-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-273-3455
-----------------------------------------------------
Fax | 800-406-8976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-277-1242
-----------------------------------------------------
Fax | 479-277-4331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR, ENROLLMENT
-----------------------------------------------------
Name | KIMBERLY CANONIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-853-0515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 99-200
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RO00006000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | TX377
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 400-0003
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 126
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 261465
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 22-01391
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHA-MOP-LIC-37
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2002012999
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 3242
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054.013662
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 4785OS
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 64000067A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #14
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 03779/7.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #15
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | OS01265
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------