Organization
SUPER D DRUGS ACQUISITION CO.
Active
Other names
OVERTURF PHARMACY #8434
Organization subpart
No
Provider details
NPI number
Authorized official
GARY BOONE (DIRECTOR OF HME OPERATIONS)
(479) 394-6363
Entity
Organization
Contact information
Practice address
100 MAIN ST, GIDEON, MO 63848
(573) 448-5552
(573) 448-3764
Mailing address
803 HIGHWAY 71 N, MENA, AR 71953-4367
(479) 394-6363
(479) 394-1046
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
005086
MO
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2626313
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
602745408
—
MO
05
—
622745404
—
MO
Enumeration date
01/24/2007
Last updated
12/17/2009
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