Provider Demographics
NPI:1467596817
Name:SUPER ROCKWALL DRUGSTORE,LP
Entity Type:Organization
Organization Name:SUPER ROCKWALL DRUGSTORE,LP
Other - Org Name:SUPER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARITES
Authorized Official - Middle Name:TALAVERA
Authorized Official - Last Name:SERNA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:972-772-0500
Mailing Address - Street 1:3021 RIDGE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5806
Mailing Address - Country:US
Mailing Address - Phone:972-772-0500
Mailing Address - Fax:972-772-5512
Practice Address - Street 1:3021 RIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5806
Practice Address - Country:US
Practice Address - Phone:972-772-0500
Practice Address - Fax:972-772-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX223903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145240Medicaid
TX22390OtherTEXAS PHARMACY LICENSE
PH0521Medicare PIN
TX22390OtherTEXAS PHARMACY LICENSE
TX145240Medicaid
TX4645790001Medicare NSC