Provider Demographics
NPI:1497209738
Name:SAM'S CLUB
Entity type:Organization
Organization Name:SAM'S CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIRAH
Authorized Official - Middle Name:SHAFFIQ
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-522-3420
Mailing Address - Street 1:4528 FORDER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-7103
Mailing Address - Country:US
Mailing Address - Phone:314-229-0984
Mailing Address - Fax:
Practice Address - Street 1:10735 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-2403
Practice Address - Country:US
Practice Address - Phone:314-522-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130262283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy