Healthcare Provider Details

I. General information

NPI: 1922113067
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: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 1ST ST S
WILLMAR MN
56201
US

IV. Provider business mailing address

11840 VALLEY VIEW RD
EDEN PRAIRIE MN
55344-3643
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-8502
  • Fax: 320-214-8560
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 Number261654
License Number StateMN

VIII. Authorized Official

Name: STEVE MCCANN
Title or Position: VP PHARMACY
Credential:
Phone: 952-828-4531