Provider Demographics
NPI:1164448023
Name:SUPER D DRUGS ACQUISITION CO
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO
Other - Org Name:JIMS DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STROUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3311
Mailing Address - Street 1:PO BOX 757810
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38175-7810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1027 MINERAL WELLS AVE STE 2
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4908
Practice Address - Country:US
Practice Address - Phone:731-642-6840
Practice Address - Fax:731-642-9879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1061332B00000X
TNC1061333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3537701OtherMEDICAID DME
4410851OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN1199580107Medicare NSC