=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669587853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUNO'S SUPERMARKETS, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 04/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2221 HWY 78 MIDWAY PLAZA
-----------------------------------------------------
City | DORA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-648-0955
-----------------------------------------------------
Fax | 205-648-2162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 99
-----------------------------------------------------
City | MAULDIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29662-0099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-213-2587
-----------------------------------------------------
Fax | 864-213-2503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | CURTIS HARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-213-2584
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 111703
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 111703
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------