Healthcare Provider Details

I. General information

NPI: 1962549709
Provider Name (Legal Business Name): SUPER D DRUGS ACQUISITION CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 01/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3315
US

IV. Provider business mailing address

803 HIGHWAY 71 N
MENA AR
71953-4367
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-1461
  • Fax: 573-785-0831
Mailing address:
  • Phone: 479-394-6363
  • Fax: 479-394-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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