NPIMap

Organization Active NPI

Sams West Inc

Doing business as Sam's Pharmacy 10-6510

  • Community/Retail Pharmacy
  • Mankato, MN
National Provider Identifier
1417299793
Registry record updated Jun 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
264106 Issued in MN
Legal business name
SAMS WEST INC
Doing business as
Sam's Pharmacy 10-6510
Practice address
1831 Madison Ave
Mankato, MN 56001-5449
Phone
(507) 387-4205
NPI assigned
Mar 25, 2013
Last updated
Jun 16, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 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 264106 MN Primary

Addresses

Primary practice location

1831 Madison Ave
Mankato, MN 56001-5449

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445
Phone (479) 277-2611

Other identifiers 2

IdentifierTypeStateIssuer
2139769OtherPK
1417299793MedicaidMN

Other names 1

  • Sam's Pharmacy 10-6510 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 MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130807000966 MN Part B Supplier - Mass Immunization (Roster Biller Only) 1850412321 13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rochester, MN; Woodbury, MN; White Bear Lake, MN; Shakopee, MN; Saint Cloud, MN; Minneapolis, MN; Maple Grove, MN; Mankato, MN…
O20140310001272 MN DME Supplier - Pharmacy 1850412321 Practice locations: Mankato, MN

Other NPIs on the same Medicare enrollment 11

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
24D2099484Sam's Pharmacy 10-65101831 East Madison Ave, Mankato, MN 56001Certificate of waiverJul 27, 2027

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 22

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

View all 22

Member of 2

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

Locations

1831 Madison Ave
Mankato, MN 56001
Phone (507) 386-7600

NPI Registry JSON

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

{
    "created_epoch": "1364169600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750032000000",
    "number": "1417299793",
    "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": "479-277-2611",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1831 MADISON AVE",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560015449",
            "telephone_number": "507-387-4205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAMS WEST INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-25",
        "last_updated": "2025-06-16",
        "certification_date": "2025-06-16",
        "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": "MN",
            "license": "264106",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2139769",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1417299793",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.22.16.840.1.113883.3.667.2",
            "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 Pharmacy 10-6510",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mankato, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 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.