=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982122115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARENDON OUTPOST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 06/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 W 2ND ST
-----------------------------------------------------
City | CLARENDON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-874-5202
-----------------------------------------------------
Fax | 806-874-5204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 927
-----------------------------------------------------
City | CLARENDON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79226-0927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-874-5202
-----------------------------------------------------
Fax | 806-874-5204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | ELMONETTE E BIVENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-874-5202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 16767
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------