=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659679066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. CLAYTON ROBERT FORD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2011
-----------------------------------------------------
Last Update Date | 03/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 934 S LONG DR
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28379-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-997-3137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 LODGE POLE LN
-----------------------------------------------------
City | PINEHURST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28374-9350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-221-9343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 21561
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------