Provider Demographics
NPI:1245635572
Name:SUPER V DRUGS VACCINES
Entity type:Organization
Organization Name:SUPER V DRUGS VACCINES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-972-6470
Mailing Address - Street 1:1000 E MATTHEWS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4344
Mailing Address - Country:US
Mailing Address - Phone:870-972-6470
Mailing Address - Fax:870-972-0710
Practice Address - Street 1:1000-A EAST MATTHEWS AVE.
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-6470
Practice Address - Fax:870-972-0710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAT'S SUPER V DRUGSTORE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR108213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy