Provider Demographics
NPI:1912171208
Name:SUPER D DRUGS ACQUISITION CO, INC.
Entity Type:Organization
Organization Name:SUPER D DRUGS ACQUISITION CO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-315-3154
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:217-709-2386
Mailing Address - Fax:
Practice Address - Street 1:2049 E SHILOH RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-3726
Practice Address - Country:US
Practice Address - Phone:662-286-6914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-17
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01049/01.1332B00000X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00093009OtherMEDICAID PHARMACY
MS2508224OtherNCPDP
MS00045061OtherDME MEDICAID
MS0308160001OtherMEDICARE