Provider Demographics
NPI:1700943180
Name:SUPERVALUE PHARMACY
Entity Type:Organization
Organization Name:SUPERVALUE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:H
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-258-6710
Mailing Address - Street 1:210 A VETERANS BLVD N
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 A VETERANS BLVD N
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744
Practice Address - Country:US
Practice Address - Phone:662-258-6710
Practice Address - Fax:662-258-5961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MS022000123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2586002OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2586002OtherOTHER ID NUMBER