Provider Demographics
NPI:1205853223
Name:SUPERPHARM, INC.
Entity Type:Organization
Organization Name:SUPERPHARM, INC.
Other - Org Name:FLAG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:URIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:781-599-5900
Mailing Address - Street 1:7 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1206
Mailing Address - Country:US
Mailing Address - Phone:781-599-5900
Mailing Address - Fax:781-599-5918
Practice Address - Street 1:7 WILLOW ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1206
Practice Address - Country:US
Practice Address - Phone:781-599-5900
Practice Address - Fax:781-599-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3466333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3466OtherSTATE LICENSE NUMBER
MA0407763Medicaid
MA0407763Medicaid