Provider Demographics
NPI:1780603969
Name:LETASSY HEALTH SERVICES
Entity type:Organization
Organization Name:LETASSY HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:LETASSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-785-0048
Mailing Address - Street 1:1002 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4840
Mailing Address - Country:US
Mailing Address - Phone:573-785-0048
Mailing Address - Fax:573-785-0459
Practice Address - Street 1:1002 W PINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4840
Practice Address - Country:US
Practice Address - Phone:573-785-0048
Practice Address - Fax:573-785-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO622577708332BN1400X
MO854887502251K00000X
MO0049183336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602577702Medicaid
MO622577708Medicaid
MO854887502Medicaid
MO2920190001Medicare NSC