Wal-Mart Stores Texas LLC
Organization Active NPI Community/Retail Pharmacy · Waco, TX
NPI 1639196876 · NPPES record last updated Jun 4, 2025
Key facts
- NPI
- 1639196876
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 21888 (TX)
- Legal business name
- WAL-MART STORES TEXAS LLC
- Practice address
- 4320 Franklin Ave
Waco, TX 76710-6906 - Phone
- (254) 751-0301
- NPI assigned
- Jul 16, 2006
- 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 |
|---|---|---|---|
| 45D2152480 | Walmart Pharmacy 10-0939 | Certificate of waiver | Aug 8, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100930018821 | TX | DME Supplier - Pharmacy |
7719199165 | Practice locations: Waco, TX |
| O20130611000245 | TX | Part B Supplier - Mass Immunization (Roster Biller Only) | 7719199165 | This NPI is an additional NPI on the enrollment |
National Provider Directory
- Tax ID family
- Wal-Mart Stores Teas LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 21888 | TX | Yes |
Addresses
Primary practice location
4320 Franklin Ave
Waco, TX 76710-6906
Mailing address
702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-1238
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2096586 | Other | PK | |
| 470211 | Medicaid | TX |
Other names
- WALMART PHARMACY 10-0939
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 Waco, TX
- Thomas Wilson Waggener
- Helen Ramona Waggoner
- Erin Nicole Wait
- Allison Wakely
- Wal-Mart Stores Texas LLC
- Wal-Mart Stores Texas, LP
- Wal-Mart Stores Texas, LP
- Walgreen Co
- Barbara C Walker
- Gregory Walker
All providers in Waco, 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 4, 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.