Healthcare Provider Details

I. General information

NPI: 1275616682
Provider Name (Legal Business Name): SUPER D DRUG ACQUISITION CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 12TH ST
LITTLE ROCK AR
72204-2047
US

IV. Provider business mailing address

2100 BROOKWOOD DR
LITTLE ROCK AR
72202-1734
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-9497
  • Fax: 501-664-5019
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberAR20066
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberAR20066
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY M. BOONE
Title or Position: DIRECTOR OF HME OPERATIONS
Credential:
Phone: 479-394-6363