Provider Demographics
NPI:1366259988
Name:SUPREME RX PHARMACY CORP
Entity type:Organization
Organization Name:SUPREME RX PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZRAHI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:917-991-5380
Mailing Address - Street 1:3011 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5410
Mailing Address - Country:US
Mailing Address - Phone:917-416-8471
Mailing Address - Fax:718-677-6601
Practice Address - Street 1:3011 AVENUE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5410
Practice Address - Country:US
Practice Address - Phone:917-416-8471
Practice Address - Fax:718-677-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy