Provider Demographics
NPI:1871608166
Name:SUPER PHARMACY LLC
Entity type:Organization
Organization Name:SUPER PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ENOCK
Authorized Official - Middle Name:K
Authorized Official - Last Name:ADEWUYI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:202-388-0050
Mailing Address - Street 1:1019 H ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3743
Mailing Address - Country:US
Mailing Address - Phone:202-388-0050
Mailing Address - Fax:202-388-0047
Practice Address - Street 1:1019 H ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3743
Practice Address - Country:US
Practice Address - Phone:202-388-0050
Practice Address - Fax:202-388-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRX95002543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0903458OtherNAPB
DC017028900Medicaid
DC017028900Medicaid
0903458OtherNAPB