Provider Demographics
NPI:1679623482
Name:SUPER DRUG MART INC
Entity Type:Organization
Organization Name:SUPER DRUG MART INC
Other - Org Name:SUPER DRUG MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:IBANEZ
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:210-884-2543
Mailing Address - Street 1:19010 PRIEST BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052
Mailing Address - Country:US
Mailing Address - Phone:830-709-0360
Mailing Address - Fax:830-709-0363
Practice Address - Street 1:19010 PRIEST BLVD
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052
Practice Address - Country:US
Practice Address - Phone:830-709-0360
Practice Address - Fax:830-709-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20307OtherSTATE BOARD OF PHARMACY
TX144974Medicaid
TX1208570001Medicare NSC