Provider Demographics
NPI:1073504460
Name:UNITED SUPERMARKETS, L.L.C.
Entity Type:Organization
Organization Name:UNITED SUPERMARKETS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PURSER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-791-0220
Mailing Address - Street 1:7830 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1942
Mailing Address - Country:US
Mailing Address - Phone:806-791-0220
Mailing Address - Fax:806-791-7490
Practice Address - Street 1:2105 AVENUE F NW
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-2219
Practice Address - Country:US
Practice Address - Phone:940-937-8242
Practice Address - Fax:940-937-2054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21406332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465181Medicaid
TX4594140OtherNCPDP
TX149310801Medicaid
TX465181Medicaid
4077810007Medicare NSC