Healthcare Provider Details

I. General information

NPI: 1164164976
Provider Name (Legal Business Name): ALTENBURG PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8491 MAIN ST
ALTENBURG MO
63732-6169
US

IV. Provider business mailing address

2001 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5805
US

V. Phone/Fax

Practice location:
  • Phone: 573-824-8888
  • Fax:
Mailing address:
  • Phone: 573-334-1300
  • Fax: 573-334-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ABRAHAM FUNK
Title or Position: OWNER
Credential: PHARMD
Phone: 573-334-1300