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General NPI Number Information
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NPI Number | 1528064367
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Entity Type | Organization
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Legal Business Name | SUPER D DRUG ACQUISITION CO.
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Dates
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Enumeration Date | 06/27/2005
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Last Update Date | 11/12/2009
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Provider Practice Location Address
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Address Line | 1430 W 1ST ST N
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City | PRESCOTT
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State | AR
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Zip | 71857-3339
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Country | US
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Telephone | 870-887-2717
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Fax | 870-887-2113
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Provider Business Mailing Address
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Address Line | 1430 W 1ST ST N
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City | PRESCOTT
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State | AR
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Zip | 71857-3339
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Country | US
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Telephone | 870-887-2717
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Fax | 870-887-2113
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Authorized Official
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Title or Position | DIRECTOR OF HME OPERATIONS
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Name | MR. GARY M. 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 | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 65694
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License Number State | AR
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