Provider Demographics
NPI:1609948488
Name:SUPERIOR PHARMACY OF TEMPLE TERRACE LLC
Entity Type:Organization
Organization Name:SUPERIOR PHARMACY OF TEMPLE TERRACE LLC
Other - Org Name:TEMPLE TERRACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-368-4873
Mailing Address - Street 1:9780 N 56TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5508
Mailing Address - Country:US
Mailing Address - Phone:813-989-1351
Mailing Address - Fax:813-988-4795
Practice Address - Street 1:9780 N 56TH ST STE D
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5508
Practice Address - Country:US
Practice Address - Phone:813-989-1351
Practice Address - Fax:813-988-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH209153336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL028285500Medicaid
2145069OtherPK
2145069OtherPK