Provider Demographics
NPI:1154319572
Name:ROSAUERS SUPERMARKETS INC
Entity Type:Organization
Organization Name:ROSAUERS SUPERMARKETS INC
Other - Org Name:SUPER 1 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-326-8900
Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:1815 W GARLAND
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-9000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 N HIGHWAY 395
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2005
Practice Address - Country:US
Practice Address - Phone:509-684-3151
Practice Address - Fax:509-684-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF560233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4925953OtherOTHER ID NUMBER
WA6020358Medicaid
0636370005Medicare NSC