Provider Demographics
NPI:1154807071
Name:MCCLAIN, BRENT THOMAS (PHARMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:MCCLAIN
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 1:19 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5796
Mailing Address - Country:US
Mailing Address - Phone:573-334-9125
Mailing Address - Fax:573-334-9200
Practice Address - Street 1:19 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5796
Practice Address - Country:US
Practice Address - Phone:573-334-9125
Practice Address - Fax:573-334-9200
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017022536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist