Provider Demographics
NPI:1649296716
Name:SUPER DISCOUNT PHARMACY
Entity type:Organization
Organization Name:SUPER DISCOUNT PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:423-472-2121
Mailing Address - Street 1:PO BOX 3240
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-3240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 SPRING PLACE RD SE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-3337
Practice Address - Country:US
Practice Address - Phone:423-472-2121
Practice Address - Fax:423-472-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000248333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3567483Medicaid
4417312OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN3567483Medicaid