Provider Demographics
NPI:1942449335
Name:SUPERIOR PHARMACY
Entity Type:Organization
Organization Name:SUPERIOR PHARMACY
Other - Org Name:SUPERIOR PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-619-4102
Mailing Address - Street 1:356 W SUPERIOR ST
Mailing Address - Street 2:RM 301-302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:356 W SUPERIOR ST
Practice Address - Street 2:RM 301-302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3416
Practice Address - Country:US
Practice Address - Phone:312-988-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540165333336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1482912OtherNCPDP PROVIDER IDENTIFICATION NUMBER