Provider Demographics
NPI:1902122484
Name:SUPER VALUE PHARMACY
Entity Type:Organization
Organization Name:SUPER VALUE PHARMACY
Other - Org Name:SUPER VALUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PATHURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-591-0050
Mailing Address - Street 1:825 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1267
Mailing Address - Country:US
Mailing Address - Phone:248-591-0050
Mailing Address - Fax:248-591-0080
Practice Address - Street 1:825 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1267
Practice Address - Country:US
Practice Address - Phone:248-591-0050
Practice Address - Fax:248-591-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301009333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2373835OtherNCPDP PROVIDER IDENTIFICATION NUMBER