Provider Demographics
NPI:1053454546
Name:CLEMONS, LULA M (R PH)
Entity Type:Individual
Prefix:
First Name:LULA
Middle Name:M
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1745
Mailing Address - Country:US
Mailing Address - Phone:229-242-0652
Mailing Address - Fax:
Practice Address - Street 1:3200 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1745
Practice Address - Country:US
Practice Address - Phone:229-242-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00278858A21Medicaid
GA1121944OtherNABP #