Healthcare Provider Details

I. General information

NPI: 1790302792
Provider Name (Legal Business Name): CLYDE WILLIAM BUTLER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2228 ISLAND BYU
BONHAM TX
75418-2207
US

IV. Provider business mailing address

2228 ISLAND BYU
BONHAM TX
75418-2207
US

V. Phone/Fax

Practice location:
  • Phone: 903-583-2887
  • Fax: 903-583-2122
Mailing address:
  • Phone: 903-583-2887
  • Fax: 903-583-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20742
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: