Organization
WAL-MART STORES TEXAS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
500 RICHLAND BOULEVARD, PROSPER, TX 75078
(972) 347-9572
(972) 347-9591
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 204-8550
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
Primary
31275
TX
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2172762
PK
—
05
—
471217
—
TX
Enumeration date
04/19/2017
Last updated
06/12/2025
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