Provider Demographics
NPI:1528064367
Name:SUPER D DRUG ACQUISITION CO.
Entity type:Organization
Organization Name:SUPER D DRUG 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 1:1430 W 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-3339
Mailing Address - Country:US
Mailing Address - Phone:870-887-2717
Mailing Address - Fax:870-887-2113
Practice Address - Street 1:1430 W 1ST ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3339
Practice Address - Country:US
Practice Address - Phone:870-887-2717
Practice Address - Fax:870-887-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR65694333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165425407Medicaid
AR0417926OtherPHARMACY