# WAL-MART PUERTO RICO INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** WALMART PHARMACY 10-2067
- **Organization subpart:** No

## Provider details

- **NPI number:** 1740203918
- **Authorized official:** KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
- **Authorized official phone:** (480) 277-6348

## Contact information

- **Practice address:** 975 AVE HOSTOS STE 2100, MAYAGUEZ MALL CARR 2, MAYAGUEZ, PR 00680-1252
- **Practice address phone:** (787) 265-1090
- **Practice address fax:** (479) 277-4331
- **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 | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 19-F-2163 | PR | Yes |

## Other

- **Enumeration date:** 07/26/2006
- **Last updated:** 07/17/2026