MEDICARE: MR. RICHARD GLENN CLEMENT R. PH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	7910	KY

General Provider Information

NPI Number	:	1710089099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD GLENN CLEMENT R. PH

Provider Business Mailing Address
First Line	:	578 BLUE SPRINGS BLVD
Second Line	:
City	:	CADIZ
State	:	KY
Zip	:	42211-8758
Country	:	US
Telephone Number	:	270-924-1191
Fax Number	:	270-924-1191

Provider Business Practice Location Address
First Line	:	266 E. MAIN ST.
Second Line	:
City	:	CADIZ
State	:	KY
Zip	:	42211-0390
Country	:	US
Telephone Number	:	270-522-3211
Fax Number	:	270-522-5479

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	07/08/2007

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