Healthcare Provider Details

I. General information

NPI: 1164448023
Provider Name (Legal Business Name): SUPER D DRUGS ACQUISITION CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 MINERAL WELLS AVE STE 2
PARIS TN
38242-4908
US

IV. Provider business mailing address

PO BOX 757810
MEMPHIS TN
38175-7810
US

V. Phone/Fax

Practice location:
  • Phone: 731-642-6840
  • Fax: 731-642-9879
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1061
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberC1061
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID STROUD
Title or Position: VP PHARMACY SERVICES
Credential:
Phone: 501-296-3311