1649257551 NPI number — UNITED SUPERMARKETS, L.L.C.

Table of content: (NPI 1649257551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649257551 NPI number — UNITED SUPERMARKETS, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITED SUPERMARKETS, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649257551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7830 ORLANDO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79423-1942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-791-0220
Provider Business Mailing Address Fax Number:
806-791-7490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5605 COLLEYVILLE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEYVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76034-6022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-577-5030
Provider Business Practice Location Address Fax Number:
817-577-5035
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PURSER
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
806-791-0220

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  22751 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 22751 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 465443 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH0436 . This is a "PROVIDER#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4529799 . This is a "NCPDP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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