Provider Demographics
NPI:1265198709
Name:SUPERIOR PHARMACY OF TEMPLE TERRACE LLC
Entity type:Organization
Organization Name:SUPERIOR PHARMACY OF TEMPLE TERRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-989-1351
Mailing Address - Street 1:9780 N 56TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5508
Mailing Address - Country:US
Mailing Address - Phone:813-989-1351
Mailing Address - Fax:813-988-4795
Practice Address - Street 1:9780 N 56TH ST STE D
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5508
Practice Address - Country:US
Practice Address - Phone:813-989-1351
Practice Address - Fax:813-988-4795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR PHARMACY OF TEMPLE TERRACE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021697100Medicaid