Provider Demographics
NPI:1851485148
Name:CHIEF SUPER MARKET INC
Entity Type:Organization
Organization Name:CHIEF SUPER MARKET INC
Other - Org Name:CHIEF PHARMACY AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-782-0950
Mailing Address - Street 1:1340 W HIGH ST
Mailing Address - Street 2:STE E
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5302
Mailing Address - Country:US
Mailing Address - Phone:419-784-0088
Mailing Address - Fax:419-784-2273
Practice Address - Street 1:705 DEATRICK ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2785
Practice Address - Country:US
Practice Address - Phone:419-784-0088
Practice Address - Fax:419-784-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0216958003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3668641OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH2737480Medicaid
OH2737480Medicaid