Provider Demographics
NPI:1700931458
Name:SUPER D DRUGS ACQUISITION CO.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO.
Other - Org Name:OVERTURF PHARMACY #8434
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF 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 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848
Practice Address - Country:US
Practice Address - Phone:573-448-5552
Practice Address - Fax:573-448-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0050863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2626313OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO602745408Medicaid
MO622745404Medicaid
MO602745408Medicaid