Provider Demographics
NPI:1750682852
Name:TUCKER, CLINTON THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:THOMAS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7334 SPOUT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5543
Mailing Address - Country:US
Mailing Address - Phone:770-967-4103
Mailing Address - Fax:770-967-7932
Practice Address - Street 1:7334 SPOUT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5543
Practice Address - Country:US
Practice Address - Phone:770-967-4103
Practice Address - Fax:770-967-7932
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-06
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024767183500000X
SCPH12558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist