Provider Demographics
NPI:1245709682
Name:SAM'S PRESCRIPTION SHOP, INC.
Entity type:Organization
Organization Name:SAM'S PRESCRIPTION SHOP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:S
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:
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 1:300 N. MORLEY STREET
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-0909
Practice Address - Fax:660-263-2124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No208U00000XAllopathic & Osteopathic PhysiciansClinical PharmacologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility SuppliesGroup - Single Specialty
No332S00000XSuppliersHearing Aid Equipment
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3507OtherMEDICARE MASS IMMUNIZATION BILLING NUMBER
MO10735224OtherMISSOURI TAX ID NUMBER
=========OtherEMPLOYER IDENTIFICATION NUMBER (EIN)