Provider Demographics
NPI:1033292446
Name:SUPER D DRUG ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUG ACQUISITION CO.
Other - Org Name:SUPER D DRUGS #134
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HME OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-6363
Mailing Address - Street 1:2100 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2542
Practice Address - Country:US
Practice Address - Phone:901-853-2222
Practice Address - Fax:901-854-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1921332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4421549OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN3914212OtherMEDICARE FLU
MS00440586OtherMEDICAID DME
TN9449036Medicaid
TN1452333OtherMEDICAID DME
4421549OtherOTHER ID NUMBER-COMMERCIAL NUMBER