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
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2177280	OTHER		PK

General Provider Information

NPI Number	:	1619470770
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	:	479-204-8550
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	5336 GOLDEN TRIANGLE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4406
Country	:	US
Telephone Number	:	817-898-6115
Fax Number	:	817-898-6115

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

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	06/11/2025

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