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	332B00000X	Durable Medical Equipment & Medical Supplies	004290	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437288438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER D DRUGS ACQUISITION CO.

Provider Business Mailing Address
First Line	:	803 HIGHWAY 71 N
Second Line	:
City	:	MENA
State	:	AR
Zip	:	71953-4367
Country	:	US
Telephone Number	:	479-394-6363
Fax Number	:	479-394-1046

Provider Business Practice Location Address
First Line	:	906 N DOUGLASS ST
Second Line	:
City	:	MALDEN
State	:	MO
Zip	:	63863-1514
Country	:	US
Telephone Number	:	573-276-2737
Fax Number	:	573-276-2496

Authorized Official
Title or Position	:	DIRECTOR OF HME OPERATIONS
Name	:	MR. GARY BOONE
Credential	:
Telephone Number	:	479-394-6363

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	03/16/2010

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