Provider Demographics
NPI:1679081988
Name:SMITH, CLINTON
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7739
Mailing Address - Country:US
Mailing Address - Phone:731-427-2683
Mailing Address - Fax:
Practice Address - Street 1:2171 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7739
Practice Address - Country:US
Practice Address - Phone:731-427-2683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-21
Last Update Date:2018-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist