NPIMap

Organization Active NPI

Wal-Mart Stores Texas LLC

Doing business as Wal-Mart Pharmacy 10-3014

  • Community/Retail Pharmacy
  • Dallas, TX
National Provider Identifier
1942640412
Registry record updated Jun 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
28595 Issued in TX
Legal business name
WAL-MART STORES TEXAS LLC
Doing business as
Wal-Mart Pharmacy 10-3014
Practice address
200 Short Blvd
Dallas, TX 75232-1300
Phone
(972) 232-6407
Fax
(972) 232-6401
NPI assigned
Jun 28, 2013
Last updated
Jun 5, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 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 NU
Community/Retail Pharmacy 3336C0003X 28595 TX Primary

Addresses

Primary practice location

200 Short Blvd
Dallas, TX 75232-1300

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 204-0709

Other identifiers 3

IdentifierTypeStateIssuer
2141277OtherPK
1942640412MedicaidTX
469795MedicaidTX

Other names 1

  • Wal-Mart Pharmacy 10-3014 Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

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
O20140416000495 TX DME Supplier - PharmacyDME Supplier - Optician 7719199165 Practice locations: Dallas, 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.

  • Walmart Inc.

    dba Walmart Pharmacy 10-1588

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

    Member Of

    NPD member

NPI Registry JSON

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

{
    "created_epoch": "1372377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749081600000",
    "number": "1942640412",
    "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": "479-204-0709",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 SHORT BLVD",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752321300",
            "telephone_number": "972-232-6407",
            "fax_number": "972-232-6401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES TEXAS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-28",
        "last_updated": "2025-06-05",
        "certification_date": "2025-06-05",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TX",
            "license": "28595",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2141277",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1942640412",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "469795",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.22.16.840.1.113883.3.667.2",
            "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": "Wal-Mart Pharmacy 10-3014",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dallas, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 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.