Provider Demographics
NPI:1134227127
Name:SUPER AID PHARMACY LLC
Entity type:Organization
Organization Name:SUPER AID PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-726-2993
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:VIRGINIA AVE
Mailing Address - City:RICH CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:24147-0325
Mailing Address - Country:US
Mailing Address - Phone:540-726-2993
Mailing Address - Fax:540-726-7331
Practice Address - Street 1:247 OLD VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:RICH CREEK
Practice Address - State:VA
Practice Address - Zip Code:24147-9653
Practice Address - Country:US
Practice Address - Phone:540-726-2993
Practice Address - Fax:540-726-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010022873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8515115Medicaid
VA010196477Medicaid
2105708OtherPK
2105708OtherPK
VA8515115Medicaid