Provider Demographics
NPI:1962813469
Name:SUPERVALU PHARMACIES INC
Entity Type:Organization
Organization Name:SUPERVALU PHARMACIES INC
Other - Org Name:CUB PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:SAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-828-4026
Mailing Address - Street 1:11840 VALLEY VIEW RD
Mailing Address - Street 2:ATTN: MANAGED CARE PHARMACY DEPT.
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3643
Mailing Address - Country:US
Mailing Address - Phone:952-828-4588
Mailing Address - Fax:952-947-3470
Practice Address - Street 1:1201 LARPENTEUR AVE W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6318
Practice Address - Country:US
Practice Address - Phone:651-487-4068
Practice Address - Fax:651-487-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2644693336C0003X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146382OtherPK
MN1962813469Medicaid
2146382OtherPK