Provider Demographics
NPI:1053729269
Name:SUPER, TODD (PHARMD, BCPS)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:
Last Name:SUPER
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 HEALTH PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-655-1735
Mailing Address - Fax:
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079
Practice Address - Country:US
Practice Address - Phone:269-655-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036387183500000X, 1835P1200X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy