Healthcare Provider Details

I. General information

NPI: 1588895213
Provider Name (Legal Business Name): UNITED SUPERMARKETS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MECHEM DR STE B
RUIDOSO NM
88345-6911
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-4014
  • Fax: 806-310-6274
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004305
License Number StateNM

VIII. Authorized Official

Name: KATHY GIANNAKOPOULOS
Title or Position: ENROLLMENTS MANAGER
Credential:
Phone: 208-395-3954