Provider Demographics
NPI:1528054830
Name:SUPER SAVE DRUG
Entity type:Organization
Organization Name:SUPER SAVE DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TORI
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-9392
Mailing Address - Street 1:PO BOX 4869
Mailing Address - Street 2:701 EAST CENTER
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4869
Mailing Address - Country:US
Mailing Address - Phone:208-232-7750
Mailing Address - Fax:208-233-3343
Practice Address - Street 1:701 EAST CENTER
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83205-4869
Practice Address - Country:US
Practice Address - Phone:208-232-7750
Practice Address - Fax:208-233-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME197332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0347210001Medicare NSC