Wal-Mart Stores Texas LLC
Organization Active NPI Community/Retail Pharmacy · League City, TX
NPI 1114035409 · NPPES record last updated Jun 13, 2025
Key facts
- NPI
- 1114035409
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 25085 (TX)
- Legal business name
- WAL-MART STORES TEXAS LLC
- Practice address
- 1701 W FM 646 Rd
League City, TX 77573-4968 - Phone
- (281) 337-9713
- NPI assigned
- Aug 27, 2006
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 853-0515
Corporate family (same tax ID) 24
Member of 1
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 45D2140931 | Walmart Pharmacy 10-5388 | Certificate of waiver | Dec 3, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930016661 | TX | DME Supplier - Pharmacy |
7719199165 | Practice locations: League City, TX |
| O20130611000245 | TX | Part B Supplier - Mass Immunization (Roster Biller Only) | 7719199165 | This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Wal-Mart Stores Teas LLC
Locations
1701 W FM 646 Rd
League City, TX 77573
Phone (281) 337-5430
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 25085 | TX | Yes |
Addresses
Primary practice location
1701 W FM 646 Rd
League City, TX 77573-4968
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1238
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2099372 | Other | PK | |
| 469585 | Medicaid | TX |
Other names
- WALMART PHARMACY 10-5388
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Ability Network |
Other providers in League City, TX
- Nguyet Vu
- Tam Vu
- Allison Wade
- Sara Rebecca Wagganer
- Angela Waggoner
- Wal-Mart Stores Texas LLC
- Wal-Mart Stores Texas LLC
- Wal-Mart Stores Texas, LLC
- Walgreen Co
- Walgreen Co
All providers in League City, TX · Community/Retail Pharmacy in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 13, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.