MEDICARE: WAL-MART PUERTO RICO INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	19-F-2292	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2086532	OTHER		PK

General Provider Information

NPI Number	:	1245253327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART PUERTO RICO INC

Provider Business Mailing Address
First Line	:	1 CUSTOMER DR # MS 0445
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVE LOS VETERANOS KM 134.7
Second Line	:
City	:	GUAYAMA
State	:	PR
Zip	:	00784
Country	:	US
Telephone Number	:	787-866-9409
Fax Number	:	787-866-2075

Authorized Official
Title or Position	:	SENIOR DIRECTOR, ENROLLMENT
Name	:	KIMBERLY CANONIC
Credential	:
Telephone Number	:	480-277-6348

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/28/2026

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