Provider Demographics
NPI:1174552848
Name:SUPER SAVE MARKETS
Entity type:Organization
Organization Name:SUPER SAVE MARKETS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-489-4377
Mailing Address - Street 1:655 E 300 S
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-4962
Mailing Address - Country:US
Mailing Address - Phone:801-375-5005
Mailing Address - Fax:801-375-1506
Practice Address - Street 1:655 E 300 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-4962
Practice Address - Country:US
Practice Address - Phone:801-375-5005
Practice Address - Fax:801-375-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2212502017033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========016Medicaid