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General NPI Number Information
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NPI Number | 1871548602
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Entity Type | Organization
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Legal Business Name | SUPER SAVER PHARMACY #NO 2 LLC
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 200 PARK PLACE BLVD
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City | KISSIMMEE
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State | FL
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Zip | 34741-2344
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Country | US
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Telephone | 407-846-0765
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Fax | 407-846-0738
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Provider Business Mailing Address
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Address Line | 2701 MICHIGAN AVE
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City | KISSIMMEE
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State | FL
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Zip | 34744-1214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEVAN MATHURA
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Credential |
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Telephone | 407-343-1230
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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 | PH21929
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License Number State | FL
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