Healthcare Provider Details

I. General information

NPI: 1215992920
Provider Name (Legal Business Name): MYRON CLECKNER PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST
DAYTON OH
45428-9000
US

IV. Provider business mailing address

4100 W 3RD ST
DAYTON OH
45428-9000
US

V. Phone/Fax

Practice location:
  • Phone: 937-268-6511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number040696
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: