Provider Demographics
NPI:1760464135
Name:MCLELLAN, LARRY GENE (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:GENE
Last Name:MCLELLAN
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 1:605 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-6509
Mailing Address - Country:US
Mailing Address - Phone:432-267-5759
Mailing Address - Fax:432-267-1575
Practice Address - Street 1:1002 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-2949
Practice Address - Country:US
Practice Address - Phone:432-267-2711
Practice Address - Fax:432-267-1575
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143601Medicaid
TX4581333OtherNABP NUMBER
TX0518940001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER