Basic Information
| Provider Information | |||||||||
| NPI: | 1922559343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAM'S WEST, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAM'S CLUB PHARMACY 10-4749 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771242 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 SOURTH AMITY RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012057460 | ||||||||
| FaxNumber: | 5012057459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR. HEALTHCARE 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 | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 218595407 | 05 | AR | MEDICAID |