Healthcare Provider Details

I. General information

NPI: 1528991130
Provider Name (Legal Business Name): CLINT DANIEL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 COMMON ST
LAKE CHARLES LA
70601-7350
US

IV. Provider business mailing address

2810 COMMON ST
LAKE CHARLES LA
70601-7350
US

V. Phone/Fax

Practice location:
  • Phone: 337-602-1417
  • Fax: 337-564-3029
Mailing address:
  • Phone: 337-602-1417
  • Fax: 337-564-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.016908
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: