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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	29784	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2151808	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205220787
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	:	479-277-1242
Fax Number	:

Provider Business Practice Location Address
First Line	:	5405 S RICE AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-2113
Country	:	US
Telephone Number	:	713-860-9245
Fax Number	:	713-860-9246

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

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	07/02/2025

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