Organization
SAMS WEST INC
Active
Parent organization
WAL-MART STORES INC
Other names
Sam's Pharmacy 10-4878
Organization subpart
Yes
Provider details
NPI number
Legal business name
WAL-MART STORES INC
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
5 ILLINI DR, GLEN CARBON, IL 62034-3929
(618) 692-7568
(618) 692-7633
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 204-8705
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
054018277
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2140580
PK
—
Enumeration date
03/21/2013
Last updated
06/06/2025
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