Provider Demographics
NPI:1174111710
Name:MANSKE, CLINT TYLER (PHARMD)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:TYLER
Last Name:MANSKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12617 N FM 1729
Mailing Address - Street 2:
Mailing Address - City:IDALOU
Mailing Address - State:TX
Mailing Address - Zip Code:79329-6171
Mailing Address - Country:US
Mailing Address - Phone:806-549-1243
Mailing Address - Fax:
Practice Address - Street 1:622 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBYTON
Practice Address - State:TX
Practice Address - Zip Code:79322-2243
Practice Address - Country:US
Practice Address - Phone:806-675-2001
Practice Address - Fax:806-675-7284
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist