Healthcare Provider Details

I. General information

NPI: 1659808434
Provider Name (Legal Business Name): UNITED SUPERMARKETS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 03/07/2023
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 4TH ST
LUBBOCK TX
79416-4006
US

IV. Provider business mailing address

7830 ORLANDO AVE
LUBBOCK TX
79423-1942
US

V. Phone/Fax

Practice location:
  • Phone: 806-784-1515
  • Fax: 806-784-1516
Mailing address:
  • Phone: 806-791-8113
  • 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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31491
License Number StateTX

VIII. Authorized Official

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