Provider Demographics
NPI:1275084865
Name:POPLAR BLUFF PHARMACY LLC
Entity Type:Organization
Organization Name:POPLAR BLUFF PHARMACY LLC
Other - Org Name:DILLE'S DISCOUNT PHARMACY
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:573-785-0984
Mailing Address - Street 1:2007 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:573-785-0984
Mailing Address - Fax:573-785-2257
Practice Address - Street 1:909 W PINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4958
Practice Address - Country:US
Practice Address - Phone:573-785-0984
Practice Address - Fax:573-785-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
MO20160423823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600059703Medicaid
2166615OtherPK