Basic Information
| Provider Information | |||||||||
| NPI: | 1063669877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMS WEST INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SAMS PHARMACY 10-4791 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | MAIL STOP 0445 | ||||||||
| Address2: | 702 SW 8TH ST | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771242 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 3010 LARUE ST | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678467072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202729001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MGR OF GOVERNMENT CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792048550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAL-MART STORES INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 2-10215 | KS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2117043 | 01 | PK | OTHER | 100444790H | 05 | KS | MEDICAID |