MEDICARE: UNITED SUPERMARKETS LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PH00004375	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2058864	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396784773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED SUPERMARKETS LLC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 N GUADALUPE ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1456
Country	:	US
Telephone Number	:	505-982-4806
Fax Number	:	505-666-3607

Authorized Official
Title or Position	:	ENROLLMENTS MANAGER
Name	:	KATHY GIANNAKOPOULOS
Credential	:
Telephone Number	:	208-395-3954

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	05/11/2026

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Directions to “UNITED SUPERMARKETS LLC ” Practice Location

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