Organization
SUPER D DRUGS ACQUISITION, CO.
Active
Other names
IKE'S #1
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GARY M. BOONE (DIRECTOR OF HME OPERATIONS)
(479) 394-6363
Entity
Organization
Contact information
Practice address
5040 PARK AVE, MEMPHIS, TN 38117-5709
(901) 761-9570
(901) 682-3266
Mailing address
803 HIGHWAY 71 N, MENA, AR 71953-4367
(479) 394-6363
(479) 394-1046
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
2316
TN
332H00000X
Eyewear Supplier
DPO0000000704
TN
333600000X
Pharmacy
2316
TN
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00440986
MEDICAID DME
TN
01
—
4427096
OTHER ID NUMBER-COMMERCIAL NUMBER
—
01
—
870001323
MEDICARE FLU
TN
05
—
9449785
—
TN
Enumeration date
10/23/2006
Last updated
07/07/2009
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