Provider Demographics
NPI:1740635770
Name:SUPERVALU PHARMACIES INC
Entity type:Organization
Organization Name:SUPERVALU PHARMACIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:421 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4955
Mailing Address - Country:US
Mailing Address - Phone:651-779-4023
Mailing Address - Fax:651-779-2023
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:651-439-0557
Practice Address - Fax:651-439-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2650753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159821OtherPK