Healthcare Provider Details

I. General information

NPI: 1780798751
Provider Name (Legal Business Name): FAMILY ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S HWY 53
POPLAR BLUFF MO
63901-7204
US

IV. Provider business mailing address

PO BOX 1187
POPLAR BLUFF MO
63902-1187
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-1919
  • Fax: 573-686-8450
Mailing address:
  • Phone: 573-686-1919
  • Fax: 573-686-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number004525
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2050727
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier602198707
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: DAVID WENDEL
Title or Position: PRESIDENT
Credential: RPH
Phone: 573-686-1919