MEDICARE: WALMART SC #3716

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1356479802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALMART SC #3716

Provider Business Mailing Address
First Line	:	STATE RD 2 KM 45.8
Second Line	:	PLAZA MONTE REAL
City	:	MANATI
State	:	PR
Zip	:	00674-0000
Country	:	US
Telephone Number	:	787-621-0048
Fax Number	:	787-884-4343

Provider Business Practice Location Address
First Line	:	STATE RD 2 KM 45.8
Second Line	:	PLAZA MONTE REAL
City	:	MANATI
State	:	PR
Zip	:	00674-0000
Country	:	US
Telephone Number	:	787-621-0048
Fax Number	:	787-884-4343

Authorized Official
Title or Position	:	DIR OF SPECIALTY DIVISIONS
Name	:	MR. JORGE L HERNANDEZ
Credential	:
Telephone Number	:	787-653-7777

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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Directions to “WALMART SC #3716 ” Practice Location

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