=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942202239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED SUPERMARKETS, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 07/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7830 ORLANDO AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79423-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-791-0220
-----------------------------------------------------
Fax | 806-791-7490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7830 ORLANDO AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79423-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-791-0220
-----------------------------------------------------
Fax | 806-791-7490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR PHARMACY SERVICES
-----------------------------------------------------
Name | TIM PURSER
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 806-791-0220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 4581496
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------