Healthcare Provider Details

I. General information

NPI: 1366694507
Provider Name (Legal Business Name): JUSTIN CLAY MCCONNELL CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 S HIGHWAY 377 STE 100
PILOT POINT TX
76258-4353
US

IV. Provider business mailing address

1246 S HIGHWAY 377 STE 100
PILOT POINT TX
76258-4353
US

V. Phone/Fax

Practice location:
  • Phone: 940-686-2218
  • Fax: 940-686-9286
Mailing address:
  • Phone: 940-686-2218
  • Fax: 940-686-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number108819
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: