Basic Information
Provider Information | |||||||||
NPI: | 1356368757 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAMS WEST INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAM'S PHARMACY 10-4787 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 702 SW 8TH ST | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727160445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792586724 | ||||||||
FaxNumber: | 4792774331 | ||||||||
Practice Location | |||||||||
Address1: | 200 AMERICAN BLVD W | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554201120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528886079 | ||||||||
FaxNumber: | 9528886095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 10/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GUNDBERG | ||||||||
AuthorizedOfficialFirstName: | CORY | ||||||||
AuthorizedOfficialMiddleName: | JON | ||||||||
AuthorizedOfficialTitleorPosition: | SVP | ||||||||
AuthorizedOfficialTelephone: | 4792772500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | 262274 | MN | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 470053800 | 05 | MN |   | MEDICAID | 2048384 | 01 |   | PK | OTHER |