Healthcare Provider Details

I. General information

NPI: 1235444522
Provider Name (Legal Business Name): WALMART SC #2302
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR #2 KM 56.8 BO. FLORIDA AFUERA
BARCELONETA PR
00617
US

IV. Provider business mailing address

CARR #2 KM 56.8 BO. FLORIDA AFUERA
BARCELONETA PR
00617
UM

V. Phone/Fax

Practice location:
  • Phone: 787-970-8105
  • Fax: 787-970-8115
Mailing address:
  • Phone: 787-653-8094
  • Fax: 479-277-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
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: MR. RENE PABON
Title or Position: RETAIL STRATEGIC BUSINESS DIRECTOR
Credential:
Phone: 787-653-8094