Healthcare Provider Details

I. General information

NPI: 1003158676
Provider Name (Legal Business Name): SAMS WEST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ILLINI DR
GLEN CARBON IL
62034-3929
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 618-692-7568
  • Fax: 618-692-7633
Mailing address:
  • Phone: 479-204-8705
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054018277
License Number StateIL

VIII. Authorized Official

Name: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR, ENROLLMENT
Credential:
Phone: 480-277-6348