Provider Demographics
NPI:1396191425
Name:SUPER PHARMACY INC
Entity Type:Organization
Organization Name:SUPER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DALIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-684-5056
Mailing Address - Street 1:4611 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5109
Mailing Address - Country:US
Mailing Address - Phone:510-684-5056
Mailing Address - Fax:
Practice Address - Street 1:4611 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5109
Practice Address - Country:US
Practice Address - Phone:510-684-5056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-07
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03491600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty