Healthcare Provider Details

I. General information

NPI: 1710995758
Provider Name (Legal Business Name): CLINTON MEDICAL CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAIN AVE
CLINTON IA
52732-2241
US

IV. Provider business mailing address

221 MAIN AVE
CLINTON IA
52732-2241
US

V. Phone/Fax

Practice location:
  • Phone: 563-242-1724
  • Fax: 563-243-8435
Mailing address:
  • Phone: 563-242-1724
  • Fax: 563-243-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number75
License Number StateIA

VIII. Authorized Official

Name: MR. GERALD W WHEELER
Title or Position: PRESIDENT
Credential: RPH
Phone: 563-242-1724