Provider Demographics
NPI:1114466067
Name:SUPERNAW, RITA (RPH)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:SUPERNAW
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 STROBEL RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3345
Mailing Address - Country:US
Mailing Address - Phone:203-260-0056
Mailing Address - Fax:
Practice Address - Street 1:259 STROBEL RD
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3345
Practice Address - Country:US
Practice Address - Phone:203-260-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist