Healthcare Provider Details

I. General information

NPI: 1275084865
Provider Name (Legal Business Name): POPLAR BLUFF PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 09/19/2025
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W PINE ST
POPLAR BLUFF MO
63901-4958
US

IV. Provider business mailing address

2007 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5805
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-0984
  • Fax: 573-785-2257
Mailing address:
  • Phone: 573-785-0984
  • Fax: 573-785-2257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2016042382
License Number StateMO

VIII. Authorized Official

Name: ABRAHAM FUNK
Title or Position: OWNER
Credential:
Phone: 573-785-0984