Provider Demographics
NPI:1750443446
Name:CLAN CORPORATION
Entity Type:Organization
Organization Name:CLAN CORPORATION
Other - Org Name:DBA POLYMEDIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MANIAGO
Authorized Official - Last Name:CONCEPCION
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST INTERN
Authorized Official - Phone:671-637-9683
Mailing Address - Street 1:PO BOX 9901
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-5901
Mailing Address - Country:US
Mailing Address - Phone:671-637-9683
Mailing Address - Fax:671-637-3408
Practice Address - Street 1:172 E BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-5367
Practice Address - Country:US
Practice Address - Phone:671-637-9683
Practice Address - Fax:671-637-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPCY029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty