Basic Information
| Provider Information | |||||||||
| NPI: | 1821334632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUPER STAR PHARMACY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SUPER STAR PHARMACY INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4173B BOWNE ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188880551 | ||||||||
| FaxNumber: | 7188880447 | ||||||||
| Practice Location | |||||||||
| Address1: | 4173B BOWNE ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188880551 | ||||||||
| FaxNumber: | 7188880447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2012 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAWAZ | ||||||||
| AuthorizedOfficialFirstName: | IRFAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7188880551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 031629 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5806712 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |