Provider Demographics
NPI:1447631734
Name:SUPER DRUG MART, INC.
Entity type:Organization
Organization Name:SUPER DRUG MART, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:IBANEZ
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:830-709-0360
Mailing Address - Street 1:19010 PREIST BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-3486
Mailing Address - Country:US
Mailing Address - Phone:830-709-0360
Mailing Address - Fax:830-709-0363
Practice Address - Street 1:5555 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3500
Practice Address - Country:US
Practice Address - Phone:210-495-7516
Practice Address - Fax:210-340-6998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144974Medicaid
TX20307OtherSTATE BOARD OF PHARMACY
TX144974Medicaid