Provider Demographics
NPI:1063557874
Name:DAN MCHAN STORE IN
Entity type:Organization
Organization Name:DAN MCHAN STORE IN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-326-7666
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-05-06
Deactivation Date:2008-05-02
Deactivation Code:
Reactivation Date:2008-05-06
Provider Licenses
StateLicense IDTaxonomies
MO006087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO006087OtherLICENSE