=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437459328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENEKO T CLAYBON PHARM. D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2010
-----------------------------------------------------
Last Update Date | 10/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11630 HIGHWAY 51 S
-----------------------------------------------------
City | ATOKA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38004-7129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-837-5011
-----------------------------------------------------
Fax | 901-837-5014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 291 W HARMONY DR
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38049-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-481-8107
-----------------------------------------------------
Fax | 901-837-5014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 33753
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD11217
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E-010629
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------