Provider Demographics
NPI:1295283778
Name:SUPER, JUSTIN R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
Last Name:SUPER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 LARKINS DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085
Mailing Address - Country:US
Mailing Address - Phone:131-778-7610
Mailing Address - Fax:313-778-7665
Practice Address - Street 1:21431 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3801
Practice Address - Country:US
Practice Address - Phone:313-778-7610
Practice Address - Fax:313-778-7665
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020413561835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy