Provider Demographics
NPI:1396851606
Name:SUPERVALU PHARMACIES INC
Entity Type:Organization
Organization Name:SUPERVALU PHARMACIES INC
Other - Org Name:CUB PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-828-4588
Mailing Address - Street 1:11840 VALLEY VIEW RD
Mailing Address - Street 2:ATTN: MANAGED CARE PHARMACY DEPT.
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3643
Mailing Address - Country:US
Mailing Address - Phone:952-828-4588
Mailing Address - Fax:952-947-3470
Practice Address - Street 1:1200 S RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-2484
Practice Address - Country:US
Practice Address - Phone:507-446-2524
Practice Address - Fax:507-387-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2620273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN171657300Medicaid
2048235OtherPK
0326790118Medicare NSC