1740559764 NPI number — HINES STREET PHARMACY LLC

Table of content: (NPI 1740559764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740559764 NPI number — HINES STREET PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HINES STREET PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HINES STREET PHARMACY LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740559764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1173 E HINES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REPUBLIC
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65738-1277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-735-0055
Provider Business Mailing Address Fax Number:
417-732-1529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1173 E HINES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65738-1277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-735-0055
Provider Business Practice Location Address Fax Number:
417-732-1529
Provider Enumeration Date:
12/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLANAHAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-735-0055

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2012001548 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2133471 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 609551700 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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