Wal-Mart Stores Texas LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

OS01265 Issued in AR

Legal business name

WAL-MART STORES TEXAS LLC

Doing business as

Walmart Pharmacy 10-2625

Practice address

1025 W Trinity Mills Rd
Carrollton, TX 75006-1375

Phone

(800) 273-3455

Fax

(800) 406-8976

NPI assigned

Jul 19, 2006

Last updated

Jun 12, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kimberly Canonic

Title

Senior Director, Enrollment

Phone

(480) 853-0515

Specialties & licenses 15

Addresses

Other identifiers 18

Other names 1

• WALMART PHARMACY 10-2625 Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in TX2 enrollments

Enrollment records 2

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Walmart Inc.

  dba Walmart Pharmacy 10-2050

  • Community/Retail Pharmacy
  • Henderson, NV
  • NPI 1043237142

  Member Of

  NPD member

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Aaron Broadwell

  • Pharmacist
  • Carrollton, TX
  • NPI 1043813504
  NPD (past)
• Michael William Brod

  • Pharmacist
  • Carrollton, TX
  • NPI 1295338762
  NPD (past)
• Chris Gilbert

  • Pharmacist
  • Carrollton, TX
  • NPI 1912500182
  NPD (past)
• Jerry Francis Gilbreath

  • Pharmacist
  • Carrollton, TX
  • NPI 1619570934
  NPD (past)
• Siu Hing Marr, RXPH

  • Pharmacist
  • Carrollton, TX
  • NPI 1760757926
  NPD (past)
• Linh Nguyen, RPH

  • Pharmacist
  • Carrollton, TX
  • NPI 1801652698
  NPD (past)
• Scott Roderick Bergeron, PHARMD., RPH

  • Pharmacist
  • Happy Valley, OR
  • NPI 1962656108
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749686400000",
    "number": "1215956222",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-277-1242",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1025 W TRINITY MILLS RD",
            "city": "CARROLLTON",
            "state": "TX",
            "postal_code": "750061375",
            "telephone_number": "800-273-3455",
            "fax_number": "800-406-8976"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES TEXAS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-19",
        "last_updated": "2025-06-12",
        "certification_date": "2025-06-12",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "99-200",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NJ",
            "license": "28RO00006000",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KY",
            "license": "TX377",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "SD",
            "license": "400-0003",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NE",
            "license": "126",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "261465",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KS",
            "license": "22-01391",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MT",
            "license": "PHA-MOP-LIC-37",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MO",
            "license": "2002012999",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TN",
            "license": "3242",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054.013662",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "LA",
            "license": "4785OS",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IN",
            "license": "64000067A",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MS",
            "license": "03779/7.1",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AR",
            "license": "OS01265",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100243640D",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1215956222",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6031421",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "613556",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1215956222",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "166999407",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100037990",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0162973",
            "state": "NJ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1215956222",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200538680A",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2095511",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810011244",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4582517",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PH386",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0162973",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1020965500001",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7T2283",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "470020",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "WALMART PHARMACY 10-2625",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALMART PHARMACY 10-2625",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Manik U Vora
• Cindy T Vu, COTA
• Sanketkumar Vyas
• Deborah Lee Wade, PHD
• Wal-Mart Stores Texas LLC (Walmart Pharmacy 10-1216)
• Wal-Mart Stores Texas LLC (Walmart Pharmacy 10-3198)
• Wal-Mart Stores Texas, LLC
• Wal-Mart Stores Texas, LP (Vision Center 30-1216)
• Nikki Anderson Walden, M.D.
• Walgreen Co (Walgreens #04014)

• Community/Retail Pharmacy in Carrollton, TX
• Providers in Carrollton, TX by specialty
• Community/Retail Pharmacy in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.