Basic Information
| Provider Information | |||||||||
| NPI: | 1285038109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMS EAST INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAM'S CLUB PHARMACY 10-4857 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | MAILSTOP: 0445 | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792772500 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 SW PINE ISLAND ROAD | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2398006027 | ||||||||
| FaxNumber: | 2398006030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2014 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DR. HEALTHCARE & ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4792048550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PH28751 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2148795 | 01 | PK | OTHER | 014113800 | 05 | FL | MEDICAID | 014113801 DME | 05 | FL | MEDICAID |