Healthcare Provider Details

I. General information

NPI: 1245562081
Provider Name (Legal Business Name): SAMS CLUB #6543
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PARQUE ESCORIAL BO. SAN ANTON CARR. #3
CAROLINA PR
00987
US

IV. Provider business mailing address

P.O. BOX 6010
CAROLINA PR
00987
US

V. Phone/Fax

Practice location:
  • Phone: 787-257-5230
  • Fax: 787-257-1934
Mailing address:
  • Phone: 787-257-5230
  • Fax: 787-257-1934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. RENE PABON
Title or Position: RETAIL STRATEGIC BUSINESS DIRECTOR
Credential:
Phone: 787-653-8094