MEDICARE: BRUNO'S 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	112053	AL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0131057	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1831204023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUNO'S SUPERMARKETS, LLC.

Provider Business Mailing Address
First Line	:	PO BOX 99
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-0099
Country	:	US
Telephone Number	:	864-213-2587
Fax Number	:	864-213-2503

Provider Business Practice Location Address
First Line	:	4750 EASTERN VALLEY RD
Second Line	:
City	:	MC CALLA
State	:	AL
Zip	:	35111-3406
Country	:	US
Telephone Number	:	205-477-4427
Fax Number	:	205-477-3397

Authorized Official
Title or Position	:	SR. DIRECTOR OF PHARMACY
Name	:	CURTIS HARTIN
Credential	:
Telephone Number	:	864-213-2584

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	12/05/2007

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