Provider Demographics
NPI:1073171385
Name:SUPERIOR CARE PHARMACY LLC
Entity type:Organization
Organization Name:SUPERIOR CARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-914-3166
Mailing Address - Street 1:6636 N TELEGRAPH RD STE B
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2254
Mailing Address - Country:US
Mailing Address - Phone:313-914-3166
Mailing Address - Fax:313-914-3162
Practice Address - Street 1:6636 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2250
Practice Address - Country:US
Practice Address - Phone:313-445-5626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-01
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073171385Medicaid