Healthcare Provider Details

I. General information

NPI: 1891381265
Provider Name (Legal Business Name): CIP NORTHSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 CATCLAW DR STE 2
ABILENE TX
79606-8253
US

IV. Provider business mailing address

1113 MURFREESBORO RD STE 106-410
FRANKLIN TN
37064-1306
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. CODY CLARK
Title or Position: MANAGING OFFICER
Credential: PHARM.D.
Phone: 806-451-4799