=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699014514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART PUERTO RICO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2013
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 2 AVE R H TODD ESQ CALLE CORCHADO SANTURCE
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-641-5606
-----------------------------------------------------
Fax | 787-945-5016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-204-0709
-----------------------------------------------------
Fax | 479-277-4331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR, ENROLLMENT
-----------------------------------------------------
Name | KIMBERLY CANONIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-277-6348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 19-F-3103
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------