Provider Demographics
NPI:1093966830
Name:MCCLATCHY, JOHN WALTER (R PH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:MCCLATCHY
Suffix:
Gender:M
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 1:325 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9658
Mailing Address - Country:US
Mailing Address - Phone:541-469-1643
Mailing Address - Fax:541-469-1637
Practice Address - Street 1:325 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9658
Practice Address - Country:US
Practice Address - Phone:541-469-1643
Practice Address - Fax:541-469-1637
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist