Healthcare Provider Details

I. General information

NPI: 1538297080
Provider Name (Legal Business Name): WALMART SC #3693
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA SANTA ISABEL STATE RD #153
SANTA ISABEL PR
00757-0000
US

IV. Provider business mailing address

PO BOX 780
SANTA ISABEL PR
00757-0780
US

V. Phone/Fax

Practice location:
  • Phone: 787-971-1005
  • Fax: 787-845-0411
Mailing address:
  • Phone: 787-971-1005
  • Fax: 787-845-0411

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. JORGE L HERNANDEZ
Title or Position: DIR OF SPECIALTY DIVISIONS
Credential:
Phone: 787-653-7777