Provider Demographics
NPI:1487744678
Name:SAM'S CLUB PHARMACY
Entity type:Organization
Organization Name:SAM'S CLUB PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHAMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-333-8903
Mailing Address - Street 1:7463 N STATE ROAD 37
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9440
Mailing Address - Country:US
Mailing Address - Phone:812-876-4964
Mailing Address - Fax:
Practice Address - Street 1:3205 W STATE ROAD 45
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5107
Practice Address - Country:US
Practice Address - Phone:812-333-8903
Practice Address - Fax:812-333-8906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017690A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty