Provider Demographics
NPI:1407041817
Name:SUPER DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:SUPER DISCOUNT PHARMACY LLC
Other - Org Name:SUPER DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHARU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-752-1133
Mailing Address - Street 1:1423 S COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-6577
Mailing Address - Country:US
Mailing Address - Phone:813-752-1133
Mailing Address - Fax:813-752-8866
Practice Address - Street 1:1423 S COLLINS ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-6577
Practice Address - Country:US
Practice Address - Phone:813-752-1133
Practice Address - Fax:813-752-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH228773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032194000Medicaid
2009651OtherPK
6037250001Medicare NSC