Provider Demographics
NPI:1740364850
Name:PUXICO PHARMACY, LLC
Entity type:Organization
Organization Name:PUXICO PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-222-6206
Mailing Address - Street 1:2001 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5805
Mailing Address - Country:US
Mailing Address - Phone:573-222-6206
Mailing Address - Fax:573-222-6406
Practice Address - Street 1:190 E. RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:PUXICO
Practice Address - State:MO
Practice Address - Zip Code:63960
Practice Address - Country:US
Practice Address - Phone:573-222-6206
Practice Address - Fax:573-222-6406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042607333600000X
MO3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600-096-507Medicaid
MO620096503Medicaid
MO620096503Medicaid