Provider Demographics
NPI:1225186471
Name:SAM'S CLUB PHARMACY
Entity Type:Organization
Organization Name:SAM'S CLUB PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:B
Authorized Official - Last Name:BROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-733-0741
Mailing Address - Street 1:4373 CORUNNA RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4152
Mailing Address - Country:US
Mailing Address - Phone:810-733-0741
Mailing Address - Fax:810-733-0997
Practice Address - Street 1:4373 CORUNNA RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4152
Practice Address - Country:US
Practice Address - Phone:810-733-0741
Practice Address - Fax:810-733-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010077443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365080Medicaid
MI2365080Medicaid