# WAL-MART PUERTO RICO INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Sam's Pharmacy 10-6690
- **Organization subpart:** No

## Provider details

- **NPI number:** 1285860312
- **Authorized official:** KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
- **Authorized official phone:** (480) 853-0515

## Contact information

- **Practice address:** CARRETERA ESTATAL 2, 2188 AVE EDUARDO RUBERTE, PONCE, PR 00716-0601
- **Practice address phone:** (787) 843-4835
- **Practice address fax:** (787) 841-4185
- **Mailing address:** 1 CUSTOMER DR, MS 0445, BENTONVILLE, AR 72716-0445

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 19-F-2746 | PR | Yes |

## Other

- **Enumeration date:** 06/03/2009
- **Last updated:** 07/17/2026