Provider Demographics
NPI:1174666556
Name:WAL-MART PUERTO RICO INC
Entity Type:Organization
Organization Name:WAL-MART PUERTO RICO INC
Other - Org Name:WALMART PHARMACY 10-3693
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-2500
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR ESTATAL 153 KM 7.2
Practice Address - Street 2:
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757-4005
Practice Address - Country:US
Practice Address - Phone:787-971-1010
Practice Address - Fax:787-845-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
PR18-F-24153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087432OtherPK
4933290023Medicare NSC