Wal-Mart Stores Texas LLC
Organization Active NPI Community/Retail Pharmacy · Lucas, TX
NPI 1114263126 · NPPES record last updated Jun 5, 2025
Key facts
- NPI
- 1114263126
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 28362 (TX)
- Legal business name
- WAL-MART STORES TEXAS LLC
- Practice address
- 2662 W Lucas Rd
Lucas, TX 75002-7513 - Phone
- (469) 675-8110
- NPI assigned
- Dec 19, 2012
- Organization subpart
- No
Authorized official
- Name
- Kimberly Canonic
- Title
- Senior Director, Enrollment
- Phone
- (480) 277-6348
Corporate family (same tax ID) 24
Member of 1
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 45D2117436 | Walmart Pharmacy 10-5672 | Certificate of waiver | Aug 15, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130611000245 | TX | Part B Supplier - Mass Immunization (Roster Biller Only) | 7719199165 | This NPI is an additional NPI on the enrollment |
| O20130701000204 | TX | DME Supplier - Pharmacy |
7719199165 | Practice locations: Lucas, TX |
National Provider Directory
- Tax ID family
- Wal-Mart Stores Teas LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 28362 | TX | Yes |
Addresses
Primary practice location
2662 W Lucas Rd
Lucas, TX 75002-7513
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-0709
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114263126 | Medicaid | TX | |
| 2138360 | Other | PK | |
| 469961 | Medicaid | TX |
Other names
- Walmart Pharmacy 10-5672
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 Lucas, TX
- William Tooley
- Leonardo Roberto Torres
- Ultrascan Mobile Imaging
- Katarina Unger
- Mindy Lu Vujovich
- Wal-Mart Stores Texas LLC
- Marisa Webster
- Brittney Marie Westlake
- Mina William
- Tonya Williams
All providers in Lucas, 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 5, 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.