MEDICARE: SUPERVALU PHARMACIES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	261263	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2047384	OTHER		PK

General Provider Information

NPI Number	:	1205941341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERVALU PHARMACIES INC

Provider Business Mailing Address
First Line	:	11840 VALLEY VIEW RD
Second Line	:	ATTN: MANAGED CARE PHARMACY DEPT.
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-3643
Country	:	US
Telephone Number	:	952-828-4588
Fax Number	:	952-947-3470

Provider Business Practice Location Address
First Line	:	5937 NICOLLET AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-2421
Country	:	US
Telephone Number	:	612-866-9921
Fax Number	:	612-866-9860

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY SERVICES
Name	:	AARON SAPP
Credential	:
Telephone Number	:	952-828-4026

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/03/2016

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