Basic Information
| Provider Information | |||||||||
| NPI: | 1598712481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUPREME PHARMACY AND MEDICAL SUPPLIES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5908 BRECKENRIDGE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133042221 | ||||||||
| FaxNumber: | 8882398423 | ||||||||
| Practice Location | |||||||||
| Address1: | 7936 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | GLENARDEN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207061772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013228082 | ||||||||
| FaxNumber: | 3013228481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ALPESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | P04318 | MD | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 408693700 | 05 | MD | MEDICAID | 2038096 | 01 | PK | OTHER |