Provider Demographics
NPI:1528376639
Name:SAMS PRESCRIPTION SHOP INC
Entity Type:Organization
Organization Name:SAMS PRESCRIPTION SHOP INC
Other - Org Name:SAM'S HEALTH MART PHARMACY
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:(26-39586)
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:65270-2500
Practice Address - Country:US
Practice Address - Phone:660-263-6710
Practice Address - Fax:660-263-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
MO20100426823336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO60020284Medicaid
2128544OtherPK
2128544OtherPK