Provider Demographics
NPI:1003158676
Name:SAMS WEST INC
Entity Type:Organization
Organization Name:SAMS WEST INC
Other - Org Name:SAM'S PHARMACY 10-4878
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR GOVERNMENT CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8550
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-204-8705
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:5 ILLINI DR
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3929
Practice Address - Country:US
Practice Address - Phone:618-692-7568
Practice Address - Fax:618-692-7633
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-21
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540182773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140580OtherPK
2140580OtherPK
2140580OtherPK