Provider Demographics
NPI:1437224367
Name:CLAYCOMB, EARL (RPH)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:CLAYCOMB
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 1:2428 ASTARITA WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4463
Mailing Address - Country:US
Mailing Address - Phone:859-523-2613
Mailing Address - Fax:
Practice Address - Street 1:OLD ROUTE 119
Practice Address - Street 2:
Practice Address - City:MOUNT GAY
Practice Address - State:WV
Practice Address - Zip Code:25637
Practice Address - Country:US
Practice Address - Phone:304-752-1445
Practice Address - Fax:304-752-1468
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP 0003750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138875000Medicaid
WV0138875000Medicaid