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	3336C0003X	Community/Retail Pharmacy	PH00004389	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2059016	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720286156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED SUPERMARKETS LLC

Provider Business Mailing Address
First Line	:	7830 ORLANDO AVE
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79423-1942
Country	:	US
Telephone Number	:	208-395-6200
Fax Number	:	806-791-7490

Provider Business Practice Location Address
First Line	:	710 PASEO DEL PUEBLO SUR STE A
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-5998
Country	:	US
Telephone Number	:	575-758-1203
Fax Number	:	575-758-3583

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	TIM PURSER
Credential	:	CPHT
Telephone Number	:	806-791-7410

Provider Enumeration Date	:	07/06/2007
Last Update Date	:	07/19/2018

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Directions to “UNITED SUPERMARKETS LLC ” Practice Location

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