Provider Demographics
NPI:1578908778
Name:SUPER PHARM INC
Entity Type:Organization
Organization Name:SUPER PHARM INC
Other - Org Name:STATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LUIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-386-8555
Mailing Address - Street 1:15714 1/2 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5029
Mailing Address - Country:US
Mailing Address - Phone:818-386-8555
Mailing Address - Fax:818-387-6210
Practice Address - Street 1:15714 1/2 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5029
Practice Address - Country:US
Practice Address - Phone:818-386-8555
Practice Address - Fax:818-387-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY555543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56-47423OtherNCPDP
CAPHY55554OtherBOARD OF PHARMACY PERMIT
CA7026550001Medicare NSC