Provider Demographics
NPI:1508843418
Name:UNITED SUPERMARKETS LLC
Entity Type:Organization
Organization Name:UNITED SUPERMARKETS LLC
Other - Org Name:MARKET STREET PHARMACY #543
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
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:806-791-8113
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:806-791-8113
Mailing Address - Fax:806-791-7490
Practice Address - Street 1:4205 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-3971
Practice Address - Country:US
Practice Address - Phone:806-798-6115
Practice Address - Fax:806-798-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX214143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465195Medicaid
TX148870201Medicaid
2096638OtherPK
4077810022Medicare NSC
PH0341Medicare PIN