MEDICARE: MRS. ALLISON D CLEM RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	9610	AR

General Provider Information

NPI Number	:	1104812767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALLISON D CLEM RPH

Provider Business Mailing Address
First Line	:	PO BOX 863
Second Line	:
City	:	LAVACA
State	:	AR
Zip	:	72941-0863
Country	:	US
Telephone Number	:	479-674-2018
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 MARKET TRCE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8676
Country	:	US
Telephone Number	:	479-646-5505
Fax Number	:	479-649-7535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	07/08/2007

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