NPIMap

Organization Active NPI

Wal-Mart Stores Texas LLC

Doing business as Walmart Pharmacy 10-5764

  • Community/Retail Pharmacy
  • Haslet, TX
National Provider Identifier
1285073346
Registry record updated Jun 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
28485 Issued in TX
Legal business name
WAL-MART STORES TEXAS LLC
Doing business as
Walmart Pharmacy 10-5764
Practice address
2401 Avondale Haslet Rd
Haslet, TX 76052-3221
Phone
(817) 302-1731
NPI assigned
Jun 21, 2013
Last updated
Jun 16, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2025

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 28485 TX Primary

Addresses

Primary practice location

2401 Avondale Haslet Rd
Haslet, TX 76052-3221

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-8705

Other identifiers 3

IdentifierTypeStateIssuer
470000MedicaidTX
1285073346MedicaidTX
2141100OtherPK

Other names 1

  • Walmart Pharmacy 10-5764 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130611000245 TX Part B Supplier - Mass Immunization (Roster Biller Only) 7719199165 This NPI is an additional NPI on the enrollment
O20131016000902 TX DME Supplier - PharmacyDME Supplier - Optician 7719199165 Practice locations: Haslet, TX

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D2117864Walmart Pharmacy 10-57642401 Avondale Haslet Road, Haslet, TX 76052Certificate of waiverAug 23, 2026

National Provider Directory

National Provider Directory
Tax ID family
Wal-Mart Stores Teas LLC879 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 1

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

  • Walmart Inc.

    dba Walmart Pharmacy 10-1588

    • Community/Retail Pharmacy
    • Victorville, CA
    • NPI 1043237456

    Member Of

    NPD member

Locations

2401 Avondale Haslet Rd
Haslet, TX 76052
Phone (817) 302-1731

NPI Registry JSON

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

{
    "created_epoch": "1371772800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750032000000",
    "number": "1285073346",
    "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": "479-204-8705",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2401 AVONDALE HASLET RD",
            "city": "HASLET",
            "state": "TX",
            "postal_code": "760523221",
            "telephone_number": "817-302-1731"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES TEXAS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-21",
        "last_updated": "2025-06-16",
        "certification_date": "2025-06-16",
        "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": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TX",
            "license": "28485",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "470000",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1285073346",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2141100",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Walmart Pharmacy 10-5764",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Haslet, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.