Provider Demographics
NPI:1659575983
Name:CLEAR STREAM LTC, LLC
Entity Type:Organization
Organization Name:CLEAR STREAM LTC, LLC
Other - Org Name:CLEAR STREAM LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:KLEINBECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-686-4556
Mailing Address - Street 1:2210 BARRON RD STE B-012
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-4556
Mailing Address - Fax:573-686-4529
Practice Address - Street 1:2210 BARRON RD STE B-012
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-4556
Practice Address - Fax:573-686-4529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070132393336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007013239OtherPHARMACY PERMIT
K90FQ0Y00OtherHIN
MOFC0291179OtherDEA