Provider Demographics
NPI:1336402965
Name:SUPREME PHARMACY LLC
Entity Type:Organization
Organization Name:SUPREME PHARMACY LLC
Other - Org Name:METRORX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TELFIA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MUCKEROY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:281-974-2678
Mailing Address - Street 1:814 HONEA EGYPT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-3864
Mailing Address - Country:US
Mailing Address - Phone:281-974-2678
Mailing Address - Fax:281-972-8872
Practice Address - Street 1:814 HONEA EGYPT RD STE 101
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-3864
Practice Address - Country:US
Practice Address - Phone:281-974-2678
Practice Address - Fax:281-972-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX297913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149243Medicaid
2135696OtherPK
TX150188Medicaid