Supervalu Pharmacies Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

263254 Issued in MN

Legal business name

SUPERVALU PHARMACIES INC

Practice address

1177 Clarence St
Saint Paul, MN 55106-2809

Phone

(651) 774-7772

Fax

(651) 774-7799

NPI assigned

Sep 4, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jessica O'Connell

Title

Manger, Managed Care

Phone

(952) 828-4588

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• CUB PHARMACY Doing business as

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Khao Yeu Ly, PHARM.D.,R.PH.

  • Pharmacist
  • Saint Paul, MN
  • NPI 1134358583
  NPD (past)
• Jason Moua, RPH

  • Pharmacist
  • White Bear Lake, MN
  • NPI 1871274803
  NPD (past)
• Brett Nierengarten

  • Pharmacist
  • Saint Paul, MN
  • NPI 1063017200
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1220486400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487548800000",
    "number": "1336397298",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11840 VALLEY VIEW RD",
            "address_2": "ATTN: MANAGED CARE PHARMACY DEPT.",
            "city": "EDEN PRAIRIE",
            "state": "MN",
            "postal_code": "553443643",
            "telephone_number": "952-828-4588",
            "fax_number": "952-947-3470"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1177 CLARENCE ST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551062809",
            "telephone_number": "651-774-7772",
            "fax_number": "651-774-7799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUPERVALU PHARMACIES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-09-04",
        "last_updated": "2017-02-20",
        "status": "A",
        "authorized_official_last_name": "O'CONNELL",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_title_or_position": "MANGER, MANAGED CARE",
        "authorized_official_telephone_number": "952-828-4588"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "263254",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2116850",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "851930000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CUB PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Supervalu Pharmacies Inc
• Theuthmany Suphantavong
• Supporthealthmn LLC
• Supportive Housing and Managed Care Pilot
• Supportive Housing and Managed Care Pilot

• Community/Retail Pharmacy in Saint Paul, MN
• Providers in Saint Paul, MN by specialty
• Community/Retail Pharmacy in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.