Healthcare Provider Details

I. General information

NPI: 1619279791
Provider Name (Legal Business Name): WAL-MART PUERTO RICO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 CARR# 2
BARCELONETA PR
00617
US

IV. Provider business mailing address

702 SW 8TH ST.
BENTONVILLE AR
72716
US

V. Phone/Fax

Practice location:
  • Phone: 787-623-0435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DIANNA PAINTER
Title or Position: ENROLLMENT SPECIALIST
Credential:
Phone: 479-277-1238