Provider Demographics
NPI:1700416146
Name:POPP, KENNETH GREGORY II (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GREGORY
Last Name:POPP
Suffix:II
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 GOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-9133
Mailing Address - Country:US
Mailing Address - Phone:573-286-1023
Mailing Address - Fax:
Practice Address - Street 1:225 PHYSICIANS PARK STE 100
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3918
Practice Address - Country:US
Practice Address - Phone:573-778-9238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO044833OtherMISSOURI STATE BOARD OF PHARMACY