MEDICARE: SUPER D DRUG 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	65694	AR

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
2	0417926	OTHER	AR	PHARMACY

General Provider Information

NPI Number	:	1528064367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER D DRUG ACQUISITION CO.

Provider Business Mailing Address
First Line	:	1430 W 1ST ST N
Second Line	:
City	:	PRESCOTT
State	:	AR
Zip	:	71857-3339
Country	:	US
Telephone Number	:	870-887-2717
Fax Number	:	870-887-2113

Provider Business Practice Location Address
First Line	:	1430 W 1ST ST N
Second Line	:
City	:	PRESCOTT
State	:	AR
Zip	:	71857-3339
Country	:	US
Telephone Number	:	870-887-2717
Fax Number	:	870-887-2113

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	11/12/2009

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