Provider Demographics
NPI:1366694507
Name:MCCONNELL, JUSTIN CLAY (CPHT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLAY
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 S HIGHWAY 377
Mailing Address - Street 2:STE 100
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-4353
Mailing Address - Country:US
Mailing Address - Phone:940-686-2218
Mailing Address - Fax:940-686-9286
Practice Address - Street 1:1246 S HIGHWAY 377
Practice Address - Street 2:STE 100
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-4353
Practice Address - Country:US
Practice Address - Phone:940-686-2218
Practice Address - Fax:940-686-9286
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108819183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician