Provider Demographics
NPI:1740559764
Name:HINES STREET PHARMACY LLC
Entity type:Organization
Organization Name:HINES STREET PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
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:417-735-0055
Mailing Address - Fax:417-732-1529
Practice Address - Street 1:1173 E HINES ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1277
Practice Address - Country:US
Practice Address - Phone:417-735-0055
Practice Address - Fax:417-732-1529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 3336L0003X
MO20120015483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133471OtherPK
MO609551700Medicaid