Wal-Mart Stores Texas LLC
Organization Active NPI Community/Retail Pharmacy · Victoria, TX
NPI 1346582467 · NPPES record last updated Jun 9, 2025
Key facts
- NPI
- 1346582467
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 28596 (TX)
- Legal business name
- WAL-MART STORES TEXAS LLC
- Practice address
- 4001 Houston Hwy
Victoria, TX 77901-4990 - Phone
- (361) 827-7275
- Fax
- (361) 827-7276
- NPI assigned
- Mar 27, 2013
- 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 |
|---|---|---|---|
| 45D2134633 | Walmart Pharmacy 10-4194 | Certificate of waiver | Aug 6, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Wal-Mart Pharmacy 10-4194 |
Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Prosthetic Lenses: Conventional Eyeglasses|Enteral Nutrients|Surgical Dressings | Does not accept assignment |
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 |
| O20131030001870 | TX | DME Supplier - Pharmacy |
7719199165 | Practice locations: Victoria, TX |
National Provider Directory
- Tax ID family
- Wal-Mart Stores Teas LLC
Locations
4001 Houston Hwy
Victoria, TX 77901
Phone (361) 579-0717
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Community/Retail Pharmacy | 3336C0003X | 28596 | TX | Yes |
Addresses
Primary practice location
4001 Houston Hwy
Victoria, TX 77901-4990
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-8550
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2140782 | Other | PK | |
| 1346582467 | Medicaid | TX | |
| 470521 | Medicaid | TX |
Other names
- WalMart Pharmacy 10-4194
Other providers in Victoria, TX
- Erin Leigh Wagner
- Pamela Coy Wagner
- William Jordan Wagner Jr.
- Loren C Wakham
- Wal-Mart Stores Texas LLC
- Wal-Mart Stores Texas, LLC
- Wal-Mart Stores Texas, LP
- Brian Robert Walford
- Walgreen Co
- Walgreen Co
All providers in Victoria, 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 9, 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.