Provider Demographics
NPI:1295161750
Name:MCCLUNG, KIM (RPH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MCCLUNG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14516 W LACEY RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5017
Mailing Address - Country:US
Mailing Address - Phone:208-241-8785
Mailing Address - Fax:
Practice Address - Street 1:235 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6438
Practice Address - Country:US
Practice Address - Phone:208-233-3341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist