1881629780 NPI number — SUPER D DRUG ACQUISITION CO., INC.

Table of content: (NPI 1881629780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881629780 NPI number — SUPER D DRUG ACQUISITION CO., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPER D DRUG ACQUISITION CO., INC.
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:
Provider Other Organization Name Type Code:
6
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:
1881629780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39302-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-447-4095
Provider Business Mailing Address Fax Number:
601-482-7490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 OFFICE PARK DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655-3598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-234-7666
Provider Business Practice Location Address Fax Number:
662-236-1211
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOONE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
662-234-7666

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BC3200X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BP3500X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BX2000X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336C0003X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336H0001X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336L0003X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336M0002X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336S0011X , with the licence number: 04340/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 00330376 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00040337 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640870044003 . This is a "CHAMPUS/TRICARE" identifier . This identifiers is of the category "OTHER".




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