Provider Demographics
NPI:1306929922
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:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3337
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:501-296-3337
Mailing Address - Fax:501-296-3310
Practice Address - Street 1:3012 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-3497
Practice Address - Country:US
Practice Address - Phone:601-939-4813
Practice Address - Fax:601-939-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01918/01.2333600000X
MS01918012332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS330375Medicaid
2514506OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS870001323OtherMEDICARE FLU
MS00330375Medicaid
MS00440585OtherMEDICAID DME
MS1199580076Medicare NSC