Provider Demographics
NPI:1336137355
Name:FUNKHOUSER, CLINTON LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:LEE
Last Name:FUNKHOUSER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14912 E LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1326
Mailing Address - Country:US
Mailing Address - Phone:509-928-8936
Mailing Address - Fax:
Practice Address - Street 1:5520 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1211
Practice Address - Country:US
Practice Address - Phone:509-489-3603
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009581183500000X
ORRPH-0009464183500000X
MI5302032153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist