MEDICARE: EARL CLAYCOMB 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	RP 0003750	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437224367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL CLAYCOMB RPH

Provider Business Mailing Address
First Line	:	2428 ASTARITA WAY
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4463
Country	:	US
Telephone Number	:	859-523-2613
Fax Number	:

Provider Business Practice Location Address
First Line	:	OLD ROUTE 119
Second Line	:
City	:	MOUNT GAY
State	:	WV
Zip	:	25637
Country	:	US
Telephone Number	:	304-752-1445
Fax Number	:	304-752-1468

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

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	07/08/2007

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