Healthcare Provider Details

I. General information

NPI: 1679656086
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: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 PARK AVE
MEMPHIS TN
38117-5709
US

IV. Provider business mailing address

803 HIGHWAY 71 N
MENA AR
71953-4367
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-9570
  • Fax: 901-682-3266
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 Number2316
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberDPO0000000704
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2316
License Number StateTN
# 4
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