1275598435 NPI number — SUPERIOR STORES DISCOUNT DISTRIBUTORS, INC.

Table of content: (NPI 1275598435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275598435 NPI number — SUPERIOR STORES DISCOUNT DISTRIBUTORS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR STORES DISCOUNT DISTRIBUTORS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275598435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1751 N 68TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33024-3958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-983-6523
Provider Business Mailing Address Fax Number:
954-966-6770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 N 68TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33024-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-983-6523
Provider Business Practice Location Address Fax Number:
954-966-6770
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HELFAN
Authorized Official First Name:
MARJORIE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
954-983-6523

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  3201660 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R7216 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 677913198 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 951066400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 677913196 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101551500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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