MEDICARE: WAL-MART PUERTO RICO INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	19-F-2499	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2087551	OTHER		PK

General Provider Information

NPI Number	:	1114146818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART PUERTO RICO INC

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	CENTRO COM PASEO DEL PLATA
Second Line	:
City	:	DORADO
State	:	PR
Zip	:	00646-0000
Country	:	US
Telephone Number	:	787-278-5859
Fax Number	:	787-278-1398

Authorized Official
Title or Position	:	DIRECTOR OF HEALTHCARE CONTRACTING
Name	:	SARAH LITTLE
Credential	:
Telephone Number	:	479-277-2500

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	04/03/2019

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