Provider Demographics
NPI:1679512057
Name:UNITED SUPERMARKETS LLC
Entity Type:Organization
Organization Name:UNITED SUPERMARKETS LLC
Other - Org Name:ALBERTSONS MARKET PHARMACY #690
Other - Org Type:Other Name
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:CPHT
Authorized Official - Phone:806-791-7410
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:208-395-6200
Mailing Address - Fax:806-791-7490
Practice Address - Street 1:1110 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5635
Practice Address - Country:US
Practice Address - Phone:575-622-7039
Practice Address - Fax:575-622-7643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NMPH000028503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2058599OtherPK
NM73326Medicaid
2058599OtherPK