Healthcare Provider Details

I. General information

NPI: 1225075740
Provider Name (Legal Business Name): UNITED SUPERMARKETS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W CHURCH STREET
CARLSBAD NM
88220-2418
US

IV. Provider business mailing address

7830 ORLANDO AVE ATTN: SANDRA WILSON
LUBBOCK TX
79423-1942
US

V. Phone/Fax

Practice location:
  • Phone: 575-885-2165
  • Fax: 575-887-8300
Mailing address:
  • Phone: 806-791-8113
  • Fax: 806-791-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00002848
License Number StateNM

VIII. Authorized Official

Name: SANDRA WILSON
Title or Position: RX AUDIT & COMPLIANCE SPECIALIST
Credential:
Phone: 806-791-8113