=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376601492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERCO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 07/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040A INDIANA AVE
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-4355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-636-3374
-----------------------------------------------------
Fax | 601-638-5376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3040A INDIANA AVE
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-636-3374
-----------------------------------------------------
Fax | 601-638-5376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STOREY JOHN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 601-636-3374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 01368/1.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------