Provider Demographics
NPI:1265035315
Name:PHILLIPS, CLANCEY
Entity Type:Individual
Prefix:
First Name:CLANCEY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2208
Mailing Address - Country:US
Mailing Address - Phone:618-339-8389
Mailing Address - Fax:
Practice Address - Street 1:7777 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-4806
Practice Address - Country:US
Practice Address - Phone:303-481-2822
Practice Address - Fax:303-481-2832
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.00023017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist