Provider Demographics
NPI:1780766576
Name:SAM'S DRUG STORE OF ROBESON CO, LLC
Entity type:Organization
Organization Name:SAM'S DRUG STORE OF ROBESON CO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARM-D/ RPH
Authorized Official - Phone:910-774-4600
Mailing Address - Street 1:925 SEASIDE RD SW UNIT 1
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-6152
Mailing Address - Country:US
Mailing Address - Phone:910-774-4600
Mailing Address - Fax:910-739-7207
Practice Address - Street 1:925 SEASIDE RD SW UNIT 1
Practice Address - Street 2:
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-6152
Practice Address - Country:US
Practice Address - Phone:910-774-4600
Practice Address - Fax:910-739-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC098193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0785759Medicaid
NC0785501Medicaid
3427021OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3427021OtherOTHER ID NUMBER
NC5366720002Medicare NSC