NPIMap

Organization Active NPI

Sams West Inc

Doing business as Sam's Club Pharmacy 10-6979

  • Community/Retail Pharmacy
  • Ankeny, IA
National Provider Identifier
1245623016
Registry record updated Jun 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
1522 Issued in IA
Legal business name
SAMS WEST INC
Doing business as
Sam's Club Pharmacy 10-6979
Practice address
4625 SE Delaware Ave
Ankeny, IA 50021-9351
Phone
(515) 559-1995
Fax
(515) 559-1996
NPI assigned
Mar 18, 2015
Last updated
Jun 9, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kimberly Canonic
Title
Senior Director, Enrollment
Phone
(480) 277-6348

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 1522 IA Primary

Addresses

Primary practice location

4625 SE Delaware Ave
Ankeny, IA 50021-9351

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 258-2115

Other identifiers 1

IdentifierTypeStateIssuer
2150881OtherPK

Other names 1

  • Sam's Club Pharmacy 10-6979 Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20131007000220 IA Part B Supplier - Mass Immunization (Roster Biller Only) 1850412321 5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ankeny, IA; Cedar Rapids, IA; Council Bluffs, IA; Davenport, IA; Dubuque, IA; Windsor Heights, IA
O20150727002011 IA DME Supplier - PharmacyDME Supplier - Optician 1850412321 Practice locations: Ankeny, IA

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D2134352Sams Club Pharmacy 10-69794625 SE Delaware Avenue, Ankeny, IA 50021Certificate of waiverJul 31, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Sam's Club Pharmacy 10-69794625 SE Delaware Ave, Ankeny, IA 50021-9351(515) 559-1995 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Prosthetic Lenses: Conventional Eyeglasses|Enteral Nutrients|Surgical Dressings Accepts assignmentParticipating since Nov 1, 2018

National Provider Directory

National Provider Directory
Tax ID family
Ability Network283 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 11

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1426636800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749427200000",
    "number": "1245623016",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-258-2115",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4625 SE DELAWARE AVE",
            "city": "ANKENY",
            "state": "IA",
            "postal_code": "500219351",
            "telephone_number": "515-559-1995",
            "fax_number": "515-559-1996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAMS WEST INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-03-18",
        "last_updated": "2025-06-09",
        "certification_date": "2025-06-09",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-277-6348"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IA",
            "license": "1522",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2150881",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Sam's Club Pharmacy 10-6979",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ankeny, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.