Provider Demographics
NPI:1184700049
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:PO BOX 776418
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6418
Mailing Address - Country:US
Mailing Address - Phone:952-828-4588
Mailing Address - Fax:952-947-3470
Practice Address - Street 1:421 3RD ST S
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4955
Practice Address - Country:US
Practice Address - Phone:651-779-4023
Practice Address - Fax:651-779-2023
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERVALU INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00418313OtherRAILROAD MEDICARE PTAN
PHC060Medicare PIN
P00418313Medicare PIN