Provider Demographics
NPI:1487076709
Name:SAM'S CLUB
Entity type:Organization
Organization Name:SAM'S CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:OXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-546-6699
Mailing Address - Street 1:611 LYCOMING MALL CIR
Mailing Address - Street 2:
Mailing Address - City:MUNCY
Mailing Address - State:PA
Mailing Address - Zip Code:17756-1826
Mailing Address - Country:US
Mailing Address - Phone:570-308-3111
Mailing Address - Fax:
Practice Address - Street 1:611 LYCOMING MALL CIR
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-1826
Practice Address - Country:US
Practice Address - Phone:570-308-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF03523237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty