Provider Demographics
NPI:1285860312
Name:WAL-MART PUERTO RICO INC
Entity type:Organization
Organization Name:WAL-MART PUERTO RICO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANONIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-277-6348
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:479-277-1238
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:CARRETERA ESTATAL 2
Practice Address - Street 2:2188 AVE EDUARDO RUBERTE
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728-2777
Practice Address - Country:US
Practice Address - Phone:787-843-4835
Practice Address - Fax:787-841-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PR19-F-27463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120478OtherPK
4933290031Medicare NSC