Healthcare Provider Details

I. General information

NPI: 1356261705
Provider Name (Legal Business Name): SAM'S WEST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16150 GOLDEN VLY PKWY
LATHROP CA
95330-8509
US

IV. Provider business mailing address

1 CUSTOMER DR
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 209-390-0328
  • Fax: 209-390-0330
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR, BILLING
Credential:
Phone: 480-853-0515