Provider Demographics
NPI:1629149893
Name:THROGMORTON POWLESS PHARMACY
Entity Type:Organization
Organization Name:THROGMORTON POWLESS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:POWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-662-2174
Mailing Address - Street 1:123 E NORTH AVE
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2028
Mailing Address - Country:US
Mailing Address - Phone:618-662-2174
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370627101001Medicaid
IL1422548OtherNABP