Provider Demographics
NPI:1558805465
Name:SAM'S WEST, INC.
Entity Type:Organization
Organization Name:SAM'S WEST, INC.
Other - Org Name:SAM'S OPTICAL CENTER 30-4853
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, CONTRACTING AND ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-258-6724
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:479-258-6724
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:5940 PROMENADE PKWY
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108
Practice Address - Country:US
Practice Address - Phone:303-379-8039
Practice Address - Fax:303-379-8038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-12
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty