MEDICARE: WAL-MART STORES TEXAS LLC

Medicare Provider Information

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	3336S0011X	Specialty Pharmacy
4	3336C0003X	Community/Retail Pharmacy	24270	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2098512	OTHER	PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1184641243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES TEXAS LLC

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-1238
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	9460 W SAM HOUSTON PKWY S
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77099-1850
Country	:	US
Telephone Number	:	281-568-3134
Fax Number	:

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

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	06/19/2025

9460 W SAM HOUSTON PKWY S , SUITE 802
HOUSTON, TX
77099-1850

Practice Phone: 281-568-3388
Practice Fax: 281-586-9607