Provider Demographics
NPI:1689285322
Name:CLEMENTS, BRADEN
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:CLEMENTS
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 1:1021 AVALON RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2505
Mailing Address - Country:US
Mailing Address - Phone:785-764-9882
Mailing Address - Fax:
Practice Address - Street 1:400 W 23RD ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-4706
Practice Address - Country:US
Practice Address - Phone:785-832-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-109719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist