Organization
SUPERVALUE PHARMACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
H BAGWELL RPH (PIC)
(662) 258-6710
Entity
Organization
Contact information
Practice address
210 A VETERANS BLVD N, EUPORA, MS 39744
(662) 258-6710
(662) 258-5961
Mailing address
210 A VETERANS BLVD N, EUPORA, MS 39744
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
02200012
MS
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2586002
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
01/03/2007
Last updated
09/12/2007
Update your record
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