MEDICARE: SUPER D DRUGS ACQUISITION CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	6314	MO
2	3336C0003X	Community/Retail Pharmacy
3	3336L0003X	Long Term Care Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2615702	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1235212648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER D DRUGS ACQUISITION CO

Provider Business Mailing Address
First Line	:	2100 BROOKWOOD DR
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-1734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 S NATIONAL AVE STE 109
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4242
Country	:	US
Telephone Number	:	417-887-0572
Fax Number	:	417-887-0572

Authorized Official
Title or Position	:	RETAIL SUPPORT
Name	:	JOYCE STROM
Credential	:
Telephone Number	:	501-296-3312

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	09/11/2025

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