NPIMap

Organization Active NPI

Sam's West, Inc.

Doing business as Sam's Club Pharmacy 10-4808

  • Community/Retail Pharmacy
  • Springdale, AR
National Provider Identifier
1386182640
Registry record updated Jun 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
SAM'S WEST, INC.
Doing business as
Sam's Club Pharmacy 10-4808
Practice address
1517 Gene George Blvd
Springdale, AR 72762
Phone
(479) 365-8134
Fax
(479) 365-8133
NPI assigned
Feb 7, 2017
Organization subpart
Yes
Parent organization
WAL-MART STORES, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 12, 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) 853-0515

Specialties & licenses 2

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

Addresses

Primary practice location

1517 Gene George Blvd
Springdale, AR 72762

Mailing address

702 SW 8TH St
Mailstop 0445
Bentonville, AR 72716-0445
Phone (479) 277-2500

Other names 1

  • Sam's Club Pharmacy 10-4808 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 AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120928000548 AR Part B Supplier - Mass Immunization (Roster Biller Only) 1850412321 8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bentonville, AR; Conway, AR; Fayetteville, AR; Fort Smith, AR; Hot Springs, AR; Jonesboro, AR; Little Rock, AR; North Little Rock, AR…
O20170922001974 AR DME Supplier - PharmacyDME Supplier - Optician 1850412321 Practice locations: Springdale, AR

Other NPIs on the same Medicare enrollment 8

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
04D2125269Sam's Club Pharmacy 10-48081517 Gene George Blvd, Springdale, AR 72762Certificate of waiverFeb 2, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Sam's Pharmacy 10-48081517 Gene George Blvd, Springdale, AR 72762-0716(479) 365-8134 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|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
Part of
Wal Mart Pharmacy 10 2039

Organizations with this tax ID in the same state 16

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

View all 16

Member of 2

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

Locations

1517 Gene George Blvd
Springdale, AR 72762
Phone (479) 365-7166

NPI Registry JSON

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

{
    "created_epoch": "1486425600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749686400000",
    "number": "1386182640",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "address_2": "MAILSTOP 0445",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445",
            "telephone_number": "479-277-2500",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1517 GENE GEORGE BLVD",
            "city": "SPRINGDALE",
            "state": "AR",
            "postal_code": "72762",
            "telephone_number": "479-365-8134",
            "fax_number": "479-365-8133"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAM'S WEST, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WAL-MART STORES, INC.",
        "enumeration_date": "2017-02-07",
        "last_updated": "2025-06-12",
        "certification_date": "2025-06-12",
        "status": "A",
        "authorized_official_last_name": "CANONIC",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "SENIOR DIRECTOR, ENROLLMENT",
        "authorized_official_telephone_number": "480-853-0515"
    },
    "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 10-4808",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Springdale, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 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.