Provider Demographics
NPI:1033252267
Name:FOOTES SUPER DRUG INC
Entity Type:Organization
Organization Name:FOOTES SUPER DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:SAWYER
Authorized Official - Last Name:FOOTE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:870-853-5275
Mailing Address - Street 1:109 EAST ADAMS STREET
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71646
Mailing Address - Country:US
Mailing Address - Phone:870-853-5275
Mailing Address - Fax:870-853-8000
Practice Address - Street 1:109 EAST ADAMS STREET
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:AR
Practice Address - Zip Code:71646
Practice Address - Country:US
Practice Address - Phone:870-853-5275
Practice Address - Fax:870-853-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR105543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100121407Medicaid
AR100121407Medicaid