Provider Demographics
NPI:1346887833
Name:SUPREME PHARMACY INC.
Entity Type:Organization
Organization Name:SUPREME PHARMACY INC.
Other - Org Name:QUEEN MARY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEDHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-282-2000
Mailing Address - Street 1:343 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-7400
Mailing Address - Country:US
Mailing Address - Phone:718-282-2000
Mailing Address - Fax:718-282-0222
Practice Address - Street 1:343 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7400
Practice Address - Country:US
Practice Address - Phone:718-282-2000
Practice Address - Fax:718-282-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-04
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06075896Medicaid
NY06075896Medicaid