1629481353 NPI number — SAMS EAST INC

Table of content: (NPI 1629481353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629481353 NPI number — SAMS EAST INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMS EAST INC
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:
SAM'S CLUB PHARMACY 10-4109
Provider Other Organization Name Type Code:
3
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:
1629481353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 SW 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72716-0445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-277-1242
Provider Business Mailing Address Fax Number:
479-277-4331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2861 BEENE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-5575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-606-6178
Provider Business Practice Location Address Fax Number:
318-606-6006
Provider Enumeration Date:
06/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR HEALTHCARE CONTRACTING
Authorized Official Telephone Number:
479-204-8550

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY6931 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2146635 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2203533 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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