Supervalu Pharmacies Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

262027 Issued in MN

Legal business name

SUPERVALU PHARMACIES INC

Practice address

1200 S Riverfront Dr
Mankato, MN 56001-2484

Phone

(507) 446-2524

Fax

(507) 387-6996

NPI assigned

Aug 21, 2006

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

Manager 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

Locations

Practitioners 1

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

• Trisha Nicole Johnson, PHARMD

  • Pharmacist
  • Mankato, MN
  • NPI 1467056952
  NPD (past)

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

{
    "created_epoch": "1156118400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487203200000",
    "number": "1396851606",
    "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": "1200 S RIVERFRONT DR",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560012484",
            "telephone_number": "507-446-2524",
            "fax_number": "507-387-6996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUPERVALU PHARMACIES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-21",
        "last_updated": "2017-02-16",
        "status": "A",
        "authorized_official_last_name": "O'CONNELL",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_title_or_position": "MANAGER 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": "262027",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "171657300",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2048235",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CUB PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Sara Suleman, MD
• Tylen James Sullinger
• Annette Nichole Sullivan, M.D.
• Kara Marie Sullivan, MD
• Supervalu Pharmacies Inc
• Maci Marie Surat
• Surdy Psychological Services LLC
• Taryn Surdy, LAMFT
• Theodore Surdy, PHD LP
• Theodore Nash Surdy, LPCC

• Community/Retail Pharmacy in Mankato, MN
• Providers in Mankato, 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 16, 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.