Provider Demographics
NPI:1376601492
Name:SUPERCO INC
Entity Type:Organization
Organization Name:SUPERCO INC
Other - Org Name:BATTLEFIELD DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STOREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-636-3374
Mailing Address - Street 1:3040A INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180
Mailing Address - Country:US
Mailing Address - Phone:601-636-3374
Mailing Address - Fax:601-638-5376
Practice Address - Street 1:3040A INDIANA AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-4355
Practice Address - Country:US
Practice Address - Phone:601-636-3374
Practice Address - Fax:601-638-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS01368/1.13336C0003X
MS0136811.1333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044424OtherPK
MS00095419Medicaid