MEDICARE: WALMART SC #3693

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	:	1538297080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALMART SC #3693

Provider Business Mailing Address
First Line	:	PO BOX 780
Second Line	:
City	:	SANTA ISABEL
State	:	PR
Zip	:	00757-0780
Country	:	US
Telephone Number	:	787-971-1005
Fax Number	:	787-845-0411

Provider Business Practice Location Address
First Line	:	PLAZA SANTA ISABEL
Second Line	:	STATE RD #153
City	:	SANTA ISABEL
State	:	PR
Zip	:	00757-0000
Country	:	US
Telephone Number	:	787-971-1005
Fax Number	:	787-845-0411

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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