Provider Demographics
NPI:1619399771
Name:MCCLAIN, MARK RUSSELL (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RUSSELL
Last Name:MCCLAIN
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 1:801 VASSAR DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2725
Mailing Address - Country:US
Mailing Address - Phone:505-248-4027
Mailing Address - Fax:505-248-7642
Practice Address - Street 1:801 VASSAR DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2725
Practice Address - Country:US
Practice Address - Phone:505-248-4027
Practice Address - Fax:505-248-7642
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005383183500000X
CARPH 46073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist