MEDICARE: WAL-MART STORES TEXAS, LLC

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	156FX1800X	Optician
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1003997537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES TEXAS, LLC

Provider Business Mailing Address
First Line	:	1 CUSTOMER DR
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9301 FOREST LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-8982
Country	:	US
Telephone Number	:	972-437-9183
Fax Number	:

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	05/27/2026

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