Provider Demographics
NPI:1306863691
Name:SAM'S WEST, INC.
Entity Type:Organization
Organization Name:SAM'S WEST, INC.
Other - Org Name:SAMS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR- PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-2500
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:
Mailing Address - Fax:
Practice Address - Street 1:6570 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1621
Practice Address - Country:US
Practice Address - Phone:847-855-8620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALMART INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-16
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL540144563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1473052OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========010Medicaid
1250150027Medicare NSC