Healthcare Provider Details

I. General information

NPI: 1033664271
Provider Name (Legal Business Name): CLAY RASMUSSEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E MAIN AVE
CHEWELAH WA
99109-8960
US

IV. Provider business mailing address

PO BOX 107 E 102 MAIN AVE
CHEWELAH WA
99109-0107
US

V. Phone/Fax

Practice location:
  • Phone: 509-935-8611
  • Fax:
Mailing address:
  • Phone: 509-935-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00019610
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: