Provider Demographics
NPI:1649367335
Name:MCHAN, DAN (RPHPHD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:MCHAN
Suffix:
Gender:M
Credentials:RPHPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E BROADWAY
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
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600135305Medicaid
MO1228120001Medicare ID - Type Unspecified