Provider Demographics
NPI:1568902427
Name:CLINTON PHARMACY LLC
Entity Type:Organization
Organization Name:CLINTON PHARMACY LLC
Other - Org Name:CLINTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:BOAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:270-254-6667
Mailing Address - Street 1:119 E CLAY ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:KY
Mailing Address - Zip Code:42031-1222
Mailing Address - Country:US
Mailing Address - Phone:270-653-5361
Mailing Address - Fax:270-653-5511
Practice Address - Street 1:119 E CLAY ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1222
Practice Address - Country:US
Practice Address - Phone:270-653-5361
Practice Address - Fax:270-653-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-26
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP018653336C0003X
KYP078393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy