Healthcare Provider Details

I. General information

NPI: 1659987584
Provider Name (Legal Business Name): SAM'S PRESCRIPTION SHOP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MORLEY ST
MOBERLY MO
65270-2334
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

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