Healthcare Provider Details

I. General information

NPI: 1073504460
Provider Name (Legal Business Name): UNITED SUPERMARKETS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 AVENUE F NW
CHILDRESS TX
79201-2219
US

IV. Provider business mailing address

7830 ORLANDO AVE
LUBBOCK TX
79423-1942
US

V. Phone/Fax

Practice location:
  • Phone: 940-937-8242
  • Fax: 940-937-2054
Mailing address:
  • Phone: 806-791-0220
  • Fax: 806-791-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number21406
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number21406
License Number StateTX

VIII. Authorized Official

Name: TIM PURSER
Title or Position: DIRECTOR PHARMACY SERVICES
Credential: RPH
Phone: 806-791-0220