Healthcare Provider Details

I. General information

NPI: 1831635697
Provider Name (Legal Business Name): CIP NORTHSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 STATE HIGHWAY 351
ABILENE TX
79601-4746
US

IV. Provider business mailing address

3410 98TH ST STE 4-369
LUBBOCK TX
79423-3847
US

V. Phone/Fax

Practice location:
  • Phone: 325-704-4208
  • Fax: 325-305-0565
Mailing address:
  • Phone: 806-451-4799
  • Fax: 325-305-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31261
License Number StateTX

VIII. Authorized Official

Name: CODY CLARK
Title or Position: MANAGING OFFICER/OWNER/AO
Credential: PHARMD
Phone: 806-773-5958