Provider Demographics
NPI:1679554299
Name:SUPER D DRUGS ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO.
Other - Org Name:OVERTURF PHARMACY #8432
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SERVICES COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3337
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:501-296-3337
Mailing Address - Fax:501-296-3310
Practice Address - Street 1:116 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BERNIE
Practice Address - State:MO
Practice Address - Zip Code:63822-9508
Practice Address - Country:US
Practice Address - Phone:573-293-5531
Practice Address - Fax:573-293-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620202416Medicaid
MO1679554299Medicaid
MO0260980001Medicare NSC