Healthcare Provider Details

I. General information

NPI: 1780767194
Provider Name (Legal Business Name): SUPER D DRUGS ACQUISITION CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 N WASHINGTON AVE
COOKEVILLE TN
38501-1834
US

IV. Provider business mailing address

803 HIGHWAY 71 N
MENA AR
71953-4367
US

V. Phone/Fax

Practice location:
  • Phone: 931-526-9786
  • Fax: 931-520-0936
Mailing address:
  • Phone: 479-394-6363
  • Fax: 479-394-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1897
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1897
License Number StateTN
# 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