Healthcare Provider Details

I. General information

NPI: 1053702118
Provider Name (Legal Business Name): GIDEON PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN STREET
GIDEON MO
63848
US

IV. Provider business mailing address

2001 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5805
US

V. Phone/Fax

Practice location:
  • Phone: 573-448-3333
  • Fax: 573-448-3335
Mailing address:
  • Phone: 573-448-3333
  • Fax: 573-448-3335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateMO

VIII. Authorized Official

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