Provider Demographics
NPI:1780767194
Name:SUPER D DRUGS ACQUISITION CO.
Entity type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1028 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1834
Practice Address - Country:US
Practice Address - Phone:931-526-9786
Practice Address - Fax:931-520-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1897333600000X, 332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9440786Medicaid
TN1452309OtherMEDICAID DME
TN3914212OtherMEDICARE FLU
4403438OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN9440786Medicaid