Provider Demographics
NPI:1598731762
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 1:639 GRAVOIS BLUFFS BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7715
Practice Address - Country:US
Practice Address - Phone:866-615-7877
Practice Address - Fax:636-343-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2020-08-22
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
MO0254040005Medicare ID - Type Unspecified