MEDICARE: DAVE'S SUPERMARKETS 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	01-1713000	OH

Other Identifiers

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

General Provider Information

NPI Number	:	1760688030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVE'S SUPERMARKETS INC

Provider Business Mailing Address
First Line	:	16820 HARVARD AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128
Country	:	US
Telephone Number	:	216-991-8648
Fax Number	:	216-991-8655

Provider Business Practice Location Address
First Line	:	16820 HARVARD AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-2208
Country	:	US
Telephone Number	:	216-991-8648
Fax Number	:	216-991-8655

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MR. JOEL M WOLFE
Credential	:	PHARMACIST
Telephone Number	:	216-361-0735

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	08/12/2008

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Directions to “DAVE'S SUPERMARKETS INC ” Practice Location

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