Provider Demographics
NPI:1275616682
Name:SUPER D DRUG ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUG ACQUISITION CO.
Other - Org Name:USA DRUG EXPRESS #1006
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 1:4010 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2047
Practice Address - Country:US
Practice Address - Phone:501-663-9497
Practice Address - Fax:501-664-5019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR20066332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR10615OtherMEDICARE FLU
AR135607716OtherMEDICAID DME
0401048OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AR133660407Medicaid
AR135607716OtherMEDICAID DME