NPIMap

Organization Active NPI

Wal-Mart Stores Texas LLC

  • Community/Retail Pharmacy
  • Tyler, TX
National Provider Identifier
1386088078
Registry record updated Jun 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
28556 Issued in TX
Legal business name
WAL-MART STORES TEXAS LLC
Practice address
1900 E SE Loop 323
Tyler, TX 75701-8337
Phone
(903) 508-6127
Fax
(903) 508-6128
NPI assigned
Apr 24, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 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) 277-6348

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 28556 TX Primary

Addresses

Primary practice location

1900 E SE Loop 323
Tyler, TX 75701-8337

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1242

Other identifiers 3

IdentifierTypeStateIssuer
2141005OtherPK
470189MedicaidTX
1386088078MedicaidTX

Other names 1

  • Walmart Pharmacy 10-4193 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
O20140416002389 TX DME Supplier - Pharmacy 7719199165 Practice locations: Tyler, TX

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.

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.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-41931900 East SE Loop 323, Tyler, TX 75701-8337(903) 508-6127 Epoetin|Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Enteral Nutrients|Surgical Dressings Does not accept assignmentParticipating since Nov 29, 2001

NPI Registry JSON

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

{
    "created_epoch": "1366761600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749427200000",
    "number": "1386088078",
    "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": "479-204-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 E SE LOOP 323",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757018337",
            "telephone_number": "903-508-6127",
            "fax_number": "903-508-6128"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES TEXAS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-24",
        "last_updated": "2025-06-09",
        "certification_date": "2025-06-09",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-277-6348"
    },
    "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": "28556",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2141005",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "470189",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386088078",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Walmart Pharmacy 10-4193",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 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.