Provider Demographics
NPI:1255171039
Name:HINES STREET PHARMACY 2 LLC
Entity type:Organization
Organization Name:HINES STREET PHARMACY 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-735-0055
Mailing Address - Street 1:1173 E HINES ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:MARIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65705-9407
Practice Address - Country:US
Practice Address - Phone:417-735-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HINES STREET PHARMACY 2 LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty