Provider Demographics
NPI:1205833118
Name:CLARENDON OUTPOST
Entity Type:Organization
Organization Name:CLARENDON OUTPOST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ELMONETTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-874-5202
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:TX
Mailing Address - Zip Code:79226-0927
Mailing Address - Country:US
Mailing Address - Phone:806-874-5202
Mailing Address - Fax:806-874-5204
Practice Address - Street 1:619 W 2ND
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:TX
Practice Address - Zip Code:79226-0927
Practice Address - Country:US
Practice Address - Phone:806-874-5202
Practice Address - Fax:806-874-5204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X
TX16767333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010761701Medicaid
TX014359601Medicaid
TX144483Medicaid
TX014359601Medicaid