Provider Demographics
NPI:1700309325
Name:SUPER FRISCO PHARMACY LLC
Entity Type:Organization
Organization Name:SUPER FRISCO PHARMACY LLC
Other - Org Name:CENTENNIAL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-8889
Mailing Address - Street 1:5350 INDEPENDENCE PKWY STE 110A
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-4652
Mailing Address - Country:US
Mailing Address - Phone:469-656-1431
Mailing Address - Fax:469-675-3027
Practice Address - Street 1:5350 INDEPENDENCE PKWY STE 110A
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-4652
Practice Address - Country:US
Practice Address - Phone:469-656-1431
Practice Address - Fax:469-675-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX315203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000Medicaid
TX0000Medicaid
2170590OtherPK
TX00Medicaid