{
"Npi": {
"NPI": "1568489052",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "WAL-MART STORES INC",
"ParentOrgTIN": null,
"OrgName": "SAMS EAST INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "702 SW 8TH ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BENTONVILLE",
"MailingAddressStateName": "AR",
"MailingAddressPostalCode": "72716-0445",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "479-277-1242",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "27300 WIXOM RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NOVI",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48374-1120",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "248-349-6043",
"PracticeLocationAddressFaxNumber": "248-349-6121",
"EnumerationDate": "07/17/2006",
"LastUpdateDate": "06/17/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CANONIC",
"AuthorizedOfficialFirstName": "KIMBERLY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "SENIOR DIRECTOR, ENROLLMENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "480-853-0515",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "5301008421",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}