Provider Demographics
NPI:1467564385
Name:PAYLESS MARKETS INC
Entity Type:Organization
Organization Name:PAYLESS MARKETS INC
Other - Org Name:SUPERDRUG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GEN MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:671-477-9266
Mailing Address - Street 1:214 W MARINE CORPS DR
Mailing Address - Street 2:RTE 1
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-5913
Mailing Address - Country:US
Mailing Address - Phone:671-637-9783
Mailing Address - Fax:671-637-9747
Practice Address - Street 1:214 W MARINE CORPS DR
Practice Address - Street 2:RTE 1
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-5913
Practice Address - Country:US
Practice Address - Phone:671-637-9783
Practice Address - Fax:671-637-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GUPCY0263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU1467564385Medicaid
5410155OtherNCPDP PROVIDER IDENTIFICATION NUMBER