Provider Demographics
NPI:1114470598
Name:SAM'S PRESCRIPTION SHOP, INC.
Entity Type:Organization
Organization Name:SAM'S PRESCRIPTION SHOP, INC.
Other - Org Name:SAM'S HEALTH MART PHARMACY # 2 (LONG-TERM CARE)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TADRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-263-3309
Mailing Address - Street 1:PO BOX 957
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0957
Mailing Address - Country:US
Mailing Address - Phone:660-263-3309
Mailing Address - Fax:660-263-3514
Practice Address - Street 1:530 EAST 24 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-0615
Practice Address - Fax:660-263-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20100426823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162343OtherPK
MO600202824Medicaid
0680180003Medicare NSC