Provider Demographics
NPI:1801819792
Name:DAVES SUPERMARKET INC
Entity Type:Organization
Organization Name:DAVES SUPERMARKET INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-961-2005
Mailing Address - Street 1:3565 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-5443
Mailing Address - Country:US
Mailing Address - Phone:216-961-2005
Mailing Address - Fax:216-631-1544
Practice Address - Street 1:3565 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-5443
Practice Address - Country:US
Practice Address - Phone:216-961-2005
Practice Address - Fax:216-631-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-07489003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0401480002Medicare NSC