MEDICARE: SAM'S CLUB PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	RP440236	PA

General Provider Information

NPI Number	:	1306396155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAM'S CLUB PHARMACY

Provider Business Mailing Address
First Line	:	289 MT.NEBO POINT DR.
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15237
Country	:	US
Telephone Number	:	412-364-6815
Fax Number	:	412-364-6852

Provider Business Practice Location Address
First Line	:	289 MOUNT NEBO POINTE RD
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15237-1313
Country	:	US
Telephone Number	:	412-364-6815
Fax Number	:	412-364-6852

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	STEPHANIE LINDSTROM
Credential	:
Telephone Number	:	412-225-9282

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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