Provider Demographics
NPI:1245250158
Name:DAVE'S SUPERMARKET INC.
Entity type:Organization
Organization Name:DAVE'S SUPERMARKET INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-361-0735
Mailing Address - Street 1:3301 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-4313
Mailing Address - Country:US
Mailing Address - Phone:216-361-0735
Mailing Address - Fax:216-391-6091
Practice Address - Street 1:3301 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-4313
Practice Address - Country:US
Practice Address - Phone:216-361-0735
Practice Address - Fax:216-391-6091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0205481003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0401480001Medicare NSC