Provider Demographics
NPI:1356488183
Name:THROGMORTON POWLESS PHARMACY INC
Entity Type:Organization
Organization Name:THROGMORTON POWLESS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:POWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-662-2174
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-0577
Mailing Address - Country:US
Mailing Address - Phone:618-662-2174
Mailing Address - Fax:618-662-9442
Practice Address - Street 1:123 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2028
Practice Address - Country:US
Practice Address - Phone:618-662-2174
Practice Address - Fax:618-662-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370627101001Medicaid
IL370627101001Medicaid