Provider Demographics
NPI:1790374759
Name:CLEMENTS, ANDY CARTER JR
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:CARTER
Last Name:CLEMENTS
Suffix:JR
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:RHINE
Mailing Address - State:GA
Mailing Address - Zip Code:31077-0100
Mailing Address - Country:US
Mailing Address - Phone:229-385-5351
Mailing Address - Fax:
Practice Address - Street 1:119 1ST ST
Practice Address - Street 2:
Practice Address - City:RHINE
Practice Address - State:GA
Practice Address - Zip Code:31077-3044
Practice Address - Country:US
Practice Address - Phone:229-385-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH16450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist