1700931458 NPI number — SUPER D DRUGS ACQUISITION CO.

Table of content: (NPI 1700931458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700931458 NPI number — SUPER D DRUGS ACQUISITION CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPER D DRUGS ACQUISITION CO.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OVERTURF PHARMACY #8434
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700931458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GIDEON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-448-5552
Provider Business Practice Location Address Fax Number:
573-448-3764
Provider Enumeration Date:
01/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOONE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HME OPERATIONS
Authorized Official Telephone Number:
479-394-6363

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 005086 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2626313 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 602745408 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 622745404 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".