=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235990276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF CLAY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2024
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 STACY BURK DRIVE
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-1600
-----------------------------------------------------
Fax | 618-844-8625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 280
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839-0280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-2131
-----------------------------------------------------
Fax | 618-662-1482
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JENNIFER VENABLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-662-2191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------