Healthcare Provider Details

I. General information

NPI: 1659486793
Provider Name (Legal Business Name): SUPERVALU PHARMACIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14133 EDGEWOOD DR
BAXTER MN
56425-8462
US

IV. Provider business mailing address

11840 VALLEY VIEW RD ATTN: MANAGED CARE PHARMACY DEPT.
EDEN PRAIRIE MN
55344-3643
US

V. Phone/Fax

Practice location:
  • Phone: 218-855-0880
  • Fax: 218-855-0010
Mailing address:
  • Phone: 952-828-4588
  • Fax: 952-947-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number261678
License Number StateMN

VIII. Authorized Official

Name: AARON SAPP
Title or Position: DIRECTOR OF PHARMACY SERVICES
Credential:
Phone: 952-828-4026