Provider Demographics
NPI:1053689158
Name:SUPER DRUG & HERBAL STORE, INC
Entity Type:Organization
Organization Name:SUPER DRUG & HERBAL STORE, INC
Other - Org Name:LENNYS RICHFIELD FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-896-6000
Mailing Address - Street 1:508 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1864
Mailing Address - Country:US
Mailing Address - Phone:435-896-6000
Mailing Address - Fax:435-896-1975
Practice Address - Street 1:508 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1864
Practice Address - Country:US
Practice Address - Phone:435-896-6000
Practice Address - Fax:435-896-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10579480-1703333600000X, 333600000X
333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1053689158Medicaid
2133086OtherPK