Provider Demographics
NPI:1528627742
Name:CREPPEL, CLAY
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:
Last Name:CREPPEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 W NORTHERN AVE
Mailing Address - Street 2:WALMART 1001 PHARMACY
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005
Mailing Address - Country:US
Mailing Address - Phone:719-561-0951
Mailing Address - Fax:
Practice Address - Street 1:4080 W NORTHERN AVE
Practice Address - Street 2:WALMART 1001 PHARMACY
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-561-0951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist