Provider Demographics
NPI:1497828578
Name:SAM'S PROFESSIONAL PHARMACY, INC
Entity Type:Organization
Organization Name:SAM'S PROFESSIONAL PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:606-546-3317
Mailing Address - Street 1:PO BOX 1766
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-5766
Mailing Address - Country:US
Mailing Address - Phone:606-546-3317
Mailing Address - Fax:606-546-3928
Practice Address - Street 1:2 KNOX PLZ
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-7300
Practice Address - Country:US
Practice Address - Phone:606-546-3317
Practice Address - Fax:606-546-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP06975332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5400829700Medicaid
5310400001Medicare ID - Type Unspecified