MEDICARE: DAVE'S SUPERMARKET INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	020548100	OH

General Provider Information

NPI Number	:	1245250158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVE'S SUPERMARKET INC.

Provider Business Mailing Address
First Line	:	3301 PAYNE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-4313
Country	:	US
Telephone Number	:	216-361-0735
Fax Number	:	216-391-6091

Provider Business Practice Location Address
First Line	:	3301 PAYNE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-4313
Country	:	US
Telephone Number	:	216-361-0735
Fax Number	:	216-391-6091

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	JOEL MICHAEL WOLFE
Credential	:	RPH
Telephone Number	:	216-361-0735

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	12/08/2011

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