Healthcare Provider Details

I. General information

NPI: 1316984834
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: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 RIDGECREST DR SE
RIO RANCHO NM
87124-5911
US

IV. Provider business mailing address

7830 ORLANDO AVE
LUBBOCK TX
79423-1942
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-2262
  • Fax: 505-892-1163
Mailing address:
  • Phone: 208-395-6200
  • Fax: 806-791-7490

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 NumberPH00004381
License Number StateNM

VIII. Authorized Official

Name: TIM PURSER
Title or Position: DIRECTOR OF PHARMACY
Credential: CPHT
Phone: 806-791-7410