Healthcare Provider Details

I. General information

NPI: 1750455283
Provider Name (Legal Business Name): L B MCCLAREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E MAIN ST
HUMBOLDT TN
38343-3327
US

IV. Provider business mailing address

2502 CHERE CAROL RD
HUMBOLDT TN
38343-3507
US

V. Phone/Fax

Practice location:
  • Phone: 731-784-4748
  • Fax: 731-784-6838
Mailing address:
  • Phone: 731-784-4748
  • Fax: 731-784-6838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1225
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4406927
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: L MCCLAREN
Title or Position: OWNER
Credential: PD
Phone: 731-784-2621