Provider Demographics
NPI:1487792495
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 1:11840 VALLEY VIEW RD
Mailing Address - Street 2:ATTN: MANAGED CARE PHARMACY DEPT.
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3643
Mailing Address - Country:US
Mailing Address - Phone:952-828-4588
Mailing Address - Fax:952-947-3470
Practice Address - Street 1:100 XYLITE ST NE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-5809
Practice Address - Country:US
Practice Address - Phone:763-689-0185
Practice Address - Fax:763-689-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MN2629653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN833608000Medicaid
2049183OtherPK
MN833608000Medicaid