Provider Demographics
NPI:1679656086
Name:SUPER D DRUGS ACQUISITION, CO.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION, CO.
Other - Org Name:IKE'S #1
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 1:803 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 1:5040 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-5709
Practice Address - Country:US
Practice Address - Phone:901-761-9570
Practice Address - Fax:901-682-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2316332B00000X, 333600000X
TNDPO0000000704332H00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00440986OtherMEDICAID DME
TN870001323OtherMEDICARE FLU
4427096OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN9449785Medicaid
TN9449785Medicaid