Provider Demographics
NPI:1376846394
Name:SUPER SAVER PHARMACY 4 LLC
Entity type:Organization
Organization Name:SUPER SAVER PHARMACY 4 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWOUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-517-8460
Mailing Address - Street 1:520 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4531
Mailing Address - Country:US
Mailing Address - Phone:407-593-2844
Mailing Address - Fax:407-593-2845
Practice Address - Street 1:1977 ALAFAYA TRL STE 1121
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-4522
Practice Address - Country:US
Practice Address - Phone:407-593-2844
Practice Address - Fax:888-843-3886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336M0002X
FLPH251183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019007700Medicaid
2127935OtherPK