Healthcare Provider Details

I. General information

NPI: 1558814939
Provider Name (Legal Business Name): SAM'S PRESCRIPTION SHOP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N CHURCH ST
FAYETTE MO
65248-1106
US

IV. Provider business mailing address

PO BOX 957
MOBERLY MO
65270-0957
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-2275
  • Fax: 660-248-2858
Mailing address:
  • Phone: 660-263-3309
  • Fax: 660-263-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number004390
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN TADRUS
Title or Position: OFFICER
Credential:
Phone: 660-263-3309