1417171927 NPI number — SAM'S DRUG MART, LLC

Table of content: (NPI 1417171927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417171927 NPI number — SAM'S DRUG MART, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAM'S DRUG MART, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417171927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 E STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLIANCE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44601-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-821-1780
Provider Business Mailing Address Fax Number:
330-821-8045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLIANCE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44601-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-821-1780
Provider Business Practice Location Address Fax Number:
330-821-8045
Provider Enumeration Date:
04/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CALABRETTA
Authorized Official First Name:
SAM
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-821-1780

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  02-0428650 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22000000216013 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0591088 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3643839 . This is a "NCPDP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".