Provider Demographics
NPI:1235477696
Name:CLEMENTS, JACK P (RPH)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:CLEMENTS
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 1:4365 COMMERCIAL WAY
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1917
Mailing Address - Country:US
Mailing Address - Phone:352-597-8506
Mailing Address - Fax:352-597-5505
Practice Address - Street 1:4365 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1917
Practice Address - Country:US
Practice Address - Phone:352-597-8506
Practice Address - Fax:352-597-5505
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS13944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist