Provider Demographics
NPI:1093216616
Name:SUPERIOR COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:SUPERIOR COMPOUNDING PHARMACY LLC
Other - Org Name:SUPERIOR COMPOUNDING PHARMACY LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEHADEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-404-6065
Mailing Address - Street 1:46983 FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2486
Mailing Address - Country:US
Mailing Address - Phone:734-404-6065
Mailing Address - Fax:734-892-2909
Practice Address - Street 1:46983 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2486
Practice Address - Country:US
Practice Address - Phone:734-404-6065
Practice Address - Fax:734-892-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176794OtherPK