Provider Demographics
NPI:1760688030
Name:DAVE'S SUPERMARKETS INC
Entity Type:Organization
Organization Name:DAVE'S SUPERMARKETS INC
Other - Org Name:DAVE'S PHARMACY 14
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:216-361-0735
Mailing Address - Street 1:16820 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128
Mailing Address - Country:US
Mailing Address - Phone:216-991-8648
Mailing Address - Fax:216-991-8655
Practice Address - Street 1:16820 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2208
Practice Address - Country:US
Practice Address - Phone:216-991-8648
Practice Address - Fax:216-991-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01-17130003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2754327Medicaid
OH0401480004Medicare NSC