Provider Demographics
NPI:1962553941
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:USA DRUG LOCKBOX 14226
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 W STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-4224
Practice Address - Country:US
Practice Address - Phone:870-741-2361
Practice Address - Fax:870-741-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR190213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127265407Medicaid
0419021OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0419021OtherNCPDP PROVIDER IDENTIFICATION NUMBER