=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942449335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2009
-----------------------------------------------------
Last Update Date | 02/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 356 W SUPERIOR ST RM 301-302
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-988-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 356 W SUPERIOR ST RM 301-302
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALAN JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-619-4102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number | 054016533
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------