1306929922 NPI number — SUPER D DRUGS ACQUISITION CO.

Table of content: (NPI 1306929922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306929922 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:
SUPER D DRUGS #139
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:
1306929922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 BROOKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72202-1734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-296-3337
Provider Business Mailing Address Fax Number:
501-296-3310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3012 HIGHWAY 80 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEARL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39208-3497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-939-4813
Provider Business Practice Location Address Fax Number:
601-939-2749
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HME OPERATIONS
Authorized Official Telephone Number:
501-296-3337

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  01918012 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 01918/01.2 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 330375 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2514506 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 870001323 . This is a "MEDICARE FLU" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00330375 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00440585 . This is a "MEDICAID DME" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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