Provider Demographics
NPI:1437594926
Name:WAL-MART STORES TEXAS LLC
Entity type:Organization
Organization Name:WAL-MART STORES TEXAS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANONIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-277-6348
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6209
Mailing Address - Country:US
Mailing Address - Phone:479-204-8705
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:3312 PRESTON RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7404
Practice Address - Country:US
Practice Address - Phone:469-304-3124
Practice Address - Fax:972-519-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX285603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX469744Medicaid
2140501OtherPK
TX1437594926Medicaid
2140501OtherPK