Provider Demographics
NPI:1295818821
Name:SUPER D DRUGS ACQUISITION CO
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO
Other - Org Name:SUPER D EXPRESS RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RETAIL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:STROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3312
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 1:201 S 28TH AVENUE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-261-6150
Practice Address - Fax:601-261-6154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03154012332B00000X
MS03154/01.2333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3976390OtherMEDICAID DME
MS00330365Medicaid
MS330365Medicaid
2518415OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS3976390OtherMEDICAID DME