Provider Demographics
NPI:1568463107
Name:SUPER D DRUGS ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO.
Other - Org Name:NORRIDS CITY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR HME OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-6363
Mailing Address - Street 1:803 HIGHWAY 71 N
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4367
Mailing Address - Country:US
Mailing Address - Phone:479-394-6363
Mailing Address - Fax:479-394-1046
Practice Address - Street 1:906 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1514
Practice Address - Country:US
Practice Address - Phone:573-276-2737
Practice Address - Fax:573-276-2496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPS004290333600000X
MO42903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600096408Medicaid