Healthcare Provider Details

I. General information

NPI: 1639213267
Provider Name (Legal Business Name): CENTRAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 LURLYN DR
POPLAR BLUFF MO
63901-2763
US

IV. Provider business mailing address

1611 LURLYN DR
POPLAR BLUFF MO
63901-2763
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-7708
  • Fax: 573-785-7700
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number6274
License Number StateMO

VIII. Authorized Official

Name: JOHN ROBINSON
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 573-785-7708