Provider Demographics
NPI:1316537913
Name:CLOUGH, MAKINNA
Entity Type:Individual
Prefix:
First Name:MAKINNA
Middle Name:
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5914 S CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1778
Mailing Address - Country:US
Mailing Address - Phone:801-907-0312
Mailing Address - Fax:
Practice Address - Street 1:617 E RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8720
Practice Address - Country:US
Practice Address - Phone:801-656-2059
Practice Address - Fax:435-656-3059
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6543993-1717183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician