Provider Demographics
NPI:1386939874
Name:CLEM, ANDREA (PHARMD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CLEM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:BLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:720 S.W. 19TH ST.
Mailing Address - Street 2:T2727
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160
Mailing Address - Country:US
Mailing Address - Phone:405-378-5495
Mailing Address - Fax:405-378-5505
Practice Address - Street 1:720 S.W. 19TH ST.
Practice Address - Street 2:T-2727
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-378-5495
Practice Address - Fax:405-945-5505
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist