Provider Demographics
NPI:1922879683
Name:SUPERVALU PHARMACIES INC
Entity Type:Organization
Organization Name:SUPERVALU PHARMACIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-779-4023
Mailing Address - Street 1:421 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4955
Mailing Address - Country:US
Mailing Address - Phone:651-779-4023
Mailing Address - Fax:651-779-2023
Practice Address - Street 1:2480 SCOTT RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:651-779-4023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy