Provider Demographics
NPI:1114391661
Name:CLEMENS, WAYNE LEONARD (R PH)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:LEONARD
Last Name:CLEMENS
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 1:639 N. RIVERPOINT BLVD. #4E
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202
Mailing Address - Country:US
Mailing Address - Phone:509-624-1529
Mailing Address - Fax:
Practice Address - Street 1:210 E. NORTH FOOTHILLS DR.
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-325-6933
Practice Address - Fax:509-326-7176
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist