MEDICARE: SUPER ROCKWALL DRUGSTORE,LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	22390	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	22390	OTHER	TX	TEXAS PHARMACY LICENSE

General Provider Information

NPI Number	:	1467596817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER ROCKWALL DRUGSTORE,LP

Provider Business Mailing Address
First Line	:	3021 RIDGE RD
Second Line	:	SUITE 103
City	:	ROCKWALL
State	:	TX
Zip	:	75032-5806
Country	:	US
Telephone Number	:	972-772-0500
Fax Number	:	972-772-5512

Provider Business Practice Location Address
First Line	:	3021 RIDGE RD
Second Line	:	SUITE 103
City	:	ROCKWALL
State	:	TX
Zip	:	75032-5806
Country	:	US
Telephone Number	:	972-772-0500
Fax Number	:	972-772-5512

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS MARITES TALAVERA SERNA
Credential	:	RPH
Telephone Number	:	972-772-0500

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	03/11/2015

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