Healthcare Provider Details

I. General information

NPI: 1245709682
Provider Name (Legal Business Name): SAM'S PRESCRIPTION SHOP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N. MORLEY STREET
MOBERLY MO
65270
US

IV. Provider business mailing address

PO BOX 957
MOBERLY MO
65270-0957
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-0909
  • Fax: 660-263-2124
Mailing address:
  • Phone: 660-263-3309
  • Fax: 660-263-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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