Provider Demographics
NPI:1275601353
Name:DAN MCHANS STORE INC
Entity Type:Organization
Organization Name:DAN MCHANS STORE INC
Other - Org Name:DAN ANS STANS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-326-7666
Mailing Address - Street 1:103 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1621
Mailing Address - Country:US
Mailing Address - Phone:417-326-7666
Mailing Address - Fax:417-777-8073
Practice Address - Street 1:103 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1621
Practice Address - Country:US
Practice Address - Phone:417-326-7666
Practice Address - Fax:417-777-8073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006087183500000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600135305Medicaid
2604925OtherNCPDP
MO600135305Medicaid