Provider Demographics
NPI:1154404564
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:RETAIL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:STROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3312
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:
Mailing Address - Fax:
Practice Address - Street 1:2055 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4131
Practice Address - Country:US
Practice Address - Phone:601-372-0662
Practice Address - Fax:601-372-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01012012332B00000X
MS01012/01.2333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440775OtherMEDICAID DME
MS00330373Medicaid
2514114OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS330373Medicaid
MS1199580009Medicare NSC