Provider Demographics
NPI:1952707671
Name:SUPER MARKET PHARMACY
Entity Type:Organization
Organization Name:SUPER MARKET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-773-6538
Mailing Address - Street 1:5985 FLORENCE AVE STE G
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-6748
Mailing Address - Country:US
Mailing Address - Phone:323-773-6538
Mailing Address - Fax:323-773-0448
Practice Address - Street 1:5985 FLORENCE AVE STE G
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-6748
Practice Address - Country:US
Practice Address - Phone:323-773-6538
Practice Address - Fax:323-773-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA36988333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy