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	02-1712950	OH

General Provider Information

NPI Number	:	1851597124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVE'S SUPERMARKETS INC.

Provider Business Mailing Address
First Line	:	3628 MAYFIELD RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1403
Country	:	US
Telephone Number	:	216-291-8881
Fax Number	:	216-291-6104

Provider Business Practice Location Address
First Line	:	3628 MAYFIELD RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1403
Country	:	US
Telephone Number	:	216-291-8881
Fax Number	:	216-291-6104

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	:	11/19/2008

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