| Hines Street Pharmacy 2 Llc | |
|
1173 E Hines St Republic MO 65738-1277 | |
| (417) 735-0055 | |
| (417) 732-1529 |
| Full Name | Hines Street Pharmacy 2 Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1173 E Hines St, Republic, Missouri |
| Authorized Official Name and Position | Steve Mcclanahan (OWNER) |
| Authorized Official Contact | 4177350055 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Hines Street Pharmacy 2 Llc 1173 E Hines St Republic MO 65738-1277 Ph: (417) 735-0055 | Hines Street Pharmacy 2 Llc 1173 E Hines St Republic MO 65738-1277 Ph: (417) 735-0055 |
| NPI Number | 1790439842 |
|---|---|
| Provider Enumeration Date | 02/08/2022 |
| Last Update Date | 08/25/2022 |
| Medicare PECOS PAC ID | 0840685806 |
|---|---|
| Medicare Enrollment ID | O20240328002606 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790439842 | NPI | - | NPPES |
| Provider Name | Courtney Deanne Davenport |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1558145516 PECOS PAC ID: 7517313919 Enrollment ID: I20231020001632 |
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