Healthcare Provider Details

I. General information

NPI: 1487395349
Provider Name (Legal Business Name): DIANE M MCCLASKEY RPH, BCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3099
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3099
US

V. Phone/Fax

Practice location:
  • Phone: 417-328-7562
  • Fax: 417-328-1175
Mailing address:
  • Phone: 417-328-7562
  • Fax: 417-328-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number17363
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number043075
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: