Provider Demographics
NPI:1164164976
Name:ALTENBURG PHARMACY, LLC
Entity Type:Organization
Organization Name:ALTENBURG PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-334-1300
Mailing Address - Street 1:2001 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5805
Mailing Address - Country:US
Mailing Address - Phone:573-334-1300
Mailing Address - Fax:573-334-0493
Practice Address - Street 1:8491 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTENBURG
Practice Address - State:MO
Practice Address - Zip Code:63732-6169
Practice Address - Country:US
Practice Address - Phone:573-824-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy