1538297080 NPI number — WALMART SC #3693

Table of content: (NPI 1538297080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538297080 NPI number — WALMART SC #3693

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALMART SC #3693
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538297080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PLAZA SANTA ISABEL
Provider Second Line Business Practice Location Address:
STATE RD #153
Provider Business Practice Location Address City Name:
SANTA ISABEL
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00757-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-971-1005
Provider Business Practice Location Address Fax Number:
787-845-0411
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIR OF SPECIALTY DIVISIONS
Authorized Official Telephone Number:
787-653-7777

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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