Provider Demographics
NPI:1689823486
Name:HAN SAM CORP
Entity Type:Organization
Organization Name:HAN SAM CORP
Other - Org Name:RIVER'S EDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-340-3248
Mailing Address - Street 1:36919 COOK ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6069
Mailing Address - Country:US
Mailing Address - Phone:760-340-3248
Mailing Address - Fax:760-340-3258
Practice Address - Street 1:36919 COOK ST STE 102
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6069
Practice Address - Country:US
Practice Address - Phone:760-340-3248
Practice Address - Fax:760-340-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X, 3336H0001X, 3336S0011X
CAPHY49157333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689823486Medicaid
2117821OtherPK
6446470001Medicare NSC