Provider Demographics
NPI:1942553367
Name:6010 SUPER RX INC
Entity Type:Organization
Organization Name:6010 SUPER RX INC
Other - Org Name:SUPERIOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SP PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LATAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-445-8450
Mailing Address - Street 1:6010A KISSENA BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5548
Mailing Address - Country:US
Mailing Address - Phone:718-445-8450
Mailing Address - Fax:718-445-8450
Practice Address - Street 1:6010A KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5548
Practice Address - Country:US
Practice Address - Phone:718-445-8450
Practice Address - Fax:718-445-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031740333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139023OtherPK
NY03528925Medicaid