Healthcare Provider Details

I. General information

NPI: 1790439842
Provider Name (Legal Business Name): HINES STREET PHARMACY 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 E HINES ST
REPUBLIC MO
65738-1277
US

IV. Provider business mailing address

1173 E HINES ST
REPUBLIC MO
65738-1277
US

V. Phone/Fax

Practice location:
  • Phone: 417-735-0055
  • Fax: 417-732-1529
Mailing address:
  • Phone: 417-735-0055
  • Fax: 417-732-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVE MCCLANAHAN
Title or Position: OWNER
Credential:
Phone: 417-735-0055