Provider Demographics
NPI:1992007074
Name:WAL-MART PUERTO RICO
Entity Type:Organization
Organization Name:WAL-MART PUERTO RICO
Other - Org Name:SAMS CLUB OPTICAL 30-4748
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-1238
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
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 16 & CARRETERA 830
Practice Address - Street 2:
Practice Address - City:BAYAMON SOUTH
Practice Address - State:PR
Practice Address - Zip Code:00957
Practice Address - Country:US
Practice Address - Phone:787-730-3652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty