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General NPI Number Information
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NPI Number | 1831635697
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Entity Type | Organization
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Legal Business Name | CIP NORTHSIDE LLC
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 04/24/2020
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Provider Practice Location Address
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Address Line | 1640 STATE HIGHWAY 351
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City | ABILENE
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State | TX
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Zip | 79601-4746
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Country | US
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Telephone | 325-704-4208
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Fax | 325-305-0565
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Provider Business Mailing Address
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Address Line | 3410 98TH ST STE 4-369
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City | LUBBOCK
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State | TX
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Zip | 79423-3847
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Country | US
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Telephone | 806-451-4799
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Fax | 325-305-0565
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Authorized Official
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Title or Position | MANAGING OFFICER/OWNER/AO
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Name | CODY CLARK
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Credential | PHARMD
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Telephone | 806-773-5958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 31261
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License Number State | TX
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