Healthcare Provider Details

I. General information

NPI: 1003206269
Provider Name (Legal Business Name): JOHN CLYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BLUEMONT AVE
MANHATTAN KS
66502-5093
US

IV. Provider business mailing address

101 BLUEMONT AVE
MANHATTAN KS
66502-5093
US

V. Phone/Fax

Practice location:
  • Phone: 785-776-4841
  • Fax: 785-776-4842
Mailing address:
  • Phone: 785-776-4841
  • Fax: 785-776-4842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-15421
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: