Healthcare Provider Details

I. General information

NPI: 1679527477
Provider Name (Legal Business Name): MARCLO ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 EAST OAK ST
JENA LA
71342-0940
US

IV. Provider business mailing address

PO BOX 940
JENA LA
71342-0940
US

V. Phone/Fax

Practice location:
  • Phone: 318-992-5088
  • Fax: 318-992-6446
Mailing address:
  • Phone: 318-992-5088
  • Fax: 318-992-6446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0139-IR
License Number StateLA

VIII. Authorized Official

Name: MR. MARTIN E CLOESSNER JR.
Title or Position: OWNER
Credential: PD
Phone: 318-992-5088