Provider Demographics
NPI:1770187916
Name:CLINNER, KELTON JON
Entity Type:Individual
Prefix:
First Name:KELTON
Middle Name:JON
Last Name:CLINNER
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 1:8700 HIGHWAY 69 S
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-8776
Mailing Address - Country:US
Mailing Address - Phone:205-342-1401
Mailing Address - Fax:205-342-1406
Practice Address - Street 1:8700 HIGHWAY 69 S
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-8776
Practice Address - Country:US
Practice Address - Phone:205-342-1401
Practice Address - Fax:205-343-1406
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL204771835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist