Provider Demographics
NPI:1952706558
Name:SUPREME COMPOUNDING LLC
Entity Type:Organization
Organization Name:SUPREME COMPOUNDING LLC
Other - Org Name:SUPREME COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHYAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-230-2884
Mailing Address - Street 1:7346 ANTOINE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-7230
Mailing Address - Country:US
Mailing Address - Phone:281-272-0813
Mailing Address - Fax:
Practice Address - Street 1:7346 ANTOINE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77088-7230
Practice Address - Country:US
Practice Address - Phone:281-272-0813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX295213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148385OtherPK