Provider Demographics
NPI:1972594422
Name:UNITED SUPERMARKETS LLC
Entity Type:Organization
Organization Name:UNITED SUPERMARKETS LLC
Other - Org Name:AMIGOS PHARMACY #508
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PURSER
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:806-791-7410
Mailing Address - Street 1:7830 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1942
Mailing Address - Country:US
Mailing Address - Phone:208-395-6200
Mailing Address - Fax:806-791-7490
Practice Address - Street 1:2403 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-3119
Practice Address - Country:US
Practice Address - Phone:806-293-3820
Practice Address - Fax:806-293-7327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX213863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093437OtherPK
TX465174Medicaid
TX148865201Medicaid
TX465174Medicaid
2093437OtherPK