Provider Demographics
NPI:1609857226
Name:SUPER D DRUGS ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HME OPERATIONS
Authorized Official - Prefix:
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 1:212 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-2114
Practice Address - Country:US
Practice Address - Phone:573-276-2218
Practice Address - Fax:573-276-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620202408Medicaid
1199580131Medicare NSC
0260980002Medicare ID - Type Unspecified