Healthcare Provider Details

I. General information

NPI: 1275601353
Provider Name (Legal Business Name): DAN MCHANS STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E BROADWAY ST
BOLIVAR MO
65613-1621
US

IV. Provider business mailing address

103 E BROADWAY ST
BOLIVAR MO
65613-1621
US

V. Phone/Fax

Practice location:
  • Phone: 417-326-7666
  • Fax: 417-777-8073
Mailing address:
  • Phone: 417-326-7666
  • Fax: 417-777-8073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number006087
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN ROY MCHAN
Title or Position: OWNER
Credential: PHD
Phone: 417-326-7666