Provider Demographics
NPI:1508315128
Name:HAN SAM CORP
Entity Type:Organization
Organization Name:HAN SAM CORP
Other - Org Name:RIVER'S EDGE SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-292-2686
Mailing Address - Street 1:17332 VON KARMAN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6280
Mailing Address - Country:US
Mailing Address - Phone:949-393-5780
Mailing Address - Fax:949-393-5790
Practice Address - Street 1:17332 VON KARMAN AVE STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6280
Practice Address - Country:US
Practice Address - Phone:949-393-5780
Practice Address - Fax:949-393-5790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA51942333600000X, 3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508315128Medicaid