Provider Demographics
NPI:1750410536
Name:UNITED SUPERMARKETS LLC
Entity type:Organization
Organization Name:UNITED SUPERMARKETS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
Authorized Official - Phone:806-791-0220
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:806-791-0220
Mailing Address - Fax:806-791-7490
Practice Address - Street 1:900 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3006
Practice Address - Country:US
Practice Address - Phone:575-622-1984
Practice Address - Fax:575-622-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000043063336C0003X
NMPH000023903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM168Medicaid
2159535OtherPK