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General NPI Number Information
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NPI Number | 1467596817
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Entity Type | Organization
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Legal Business Name | SUPER ROCKWALL DRUGSTORE,LP
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Dates
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Enumeration Date | 02/19/2007
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Last Update Date | 03/11/2015
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Provider Practice Location Address
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Address Line | 3021 RIDGE RD SUITE 103
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City | ROCKWALL
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State | TX
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Zip | 75032-5806
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Country | US
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Telephone | 972-772-0500
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Fax | 972-772-5512
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Provider Business Mailing Address
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Address Line | 3021 RIDGE RD SUITE 103
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City | ROCKWALL
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State | TX
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Zip | 75032-5806
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Country | US
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Telephone | 972-772-0500
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Fax | 972-772-5512
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Authorized Official
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Title or Position | PRESIDENT
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Name | MISS MARITES TALAVERA SERNA
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Credential | RPH
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Telephone | 972-772-0500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 22390
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License Number State | TX
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