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General NPI Number Information
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NPI Number | 1366774374
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Entity Type | Organization
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Legal Business Name | SUPER D DRUGS ACQUISITION CO.
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Dates
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Enumeration Date | 02/02/2010
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Last Update Date | 02/02/2010
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Provider Practice Location Address
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Address Line | 513 N GRAND AVE
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City | DONIPHAN
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State | MO
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Zip | 63935-1405
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Country | US
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Telephone | 573-996-3784
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Fax | 573-996-5275
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Provider Business Mailing Address
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Address Line | 803 HIGHWAY 71 N
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City | MENA
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State | AR
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Zip | 71953-4367
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Country | US
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Telephone | 479-394-6363
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Fax | 479-394-1046
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Authorized Official
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Title or Position | DIRECTOR OF HME OPERATIONS
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Name | GARY BOONE
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Credential |
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Telephone | 479-394-6363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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