Provider Demographics
NPI:1669765277
Name:CLAYTON, WYLIE RAY SR
Entity type:Individual
Prefix:MR
First Name:WYLIE
Middle Name:RAY
Last Name:CLAYTON
Suffix:SR
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 1:1063 KY HIGHWAY 36 E
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7584
Mailing Address - Country:US
Mailing Address - Phone:859-234-5758
Mailing Address - Fax:
Practice Address - Street 1:1063 KY HIGHWAY 36 E
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7584
Practice Address - Country:US
Practice Address - Phone:859-234-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist