Healthcare Provider Details

I. General information

NPI: 1306929922
Provider Name (Legal Business Name): SUPER D DRUGS ACQUISITION CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 HIGHWAY 80 E
PEARL MS
39208-3497
US

IV. Provider business mailing address

2100 BROOKWOOD DR
LITTLE ROCK AR
72202-1734
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-4813
  • Fax: 601-939-2749
Mailing address:
  • Phone: 501-296-3337
  • Fax: 501-296-3310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number01918012
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number01918/01.2
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD COOPER
Title or Position: DIRECTOR OF HME OPERATIONS
Credential:
Phone: 501-296-3337