Provider Demographics
NPI:1275537938
Name:HOME MEDICAL SUPPLY OF POPLAR BLUFF, INC
Entity Type:Organization
Organization Name:HOME MEDICAL SUPPLY OF POPLAR BLUFF, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARGAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-682-5510
Mailing Address - Street 1:1901 SUNSET DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2820
Mailing Address - Country:US
Mailing Address - Phone:800-682-5510
Mailing Address - Fax:573-686-6846
Practice Address - Street 1:760 S KINGSHIGHWAY ST
Practice Address - Street 2:SUITE L
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7630
Practice Address - Country:US
Practice Address - Phone:888-388-0933
Practice Address - Fax:573-335-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13165593332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0254040004Medicare NSC