Healthcare Provider Details

I. General information

NPI: 1902485436
Provider Name (Legal Business Name): UNITED SUPERMARKETS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11310 SLIDE RD
LUBBOCK TX
79424
US

IV. Provider business mailing address

7830 ORLANDO AVE
LUBBOCK TX
79423-1942
US

V. Phone/Fax

Practice location:
  • Phone: 806-705-4110
  • Fax: 806-705-4111
Mailing address:
  • Phone: 806-791-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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