Provider Demographics
NPI:1487099586
Name:MCCLENDON, SAMUEL KEVIN (RPH)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KEVIN
Last Name:MCCLENDON
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 1:4581 RUTHERFORD DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8108
Mailing Address - Country:US
Mailing Address - Phone:770-650-5008
Mailing Address - Fax:
Practice Address - Street 1:455 NATHAN DEAN BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4921
Practice Address - Country:US
Practice Address - Phone:770-443-8776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist