Provider Demographics
NPI:1770754533
Name:CLAY, RICKEY EDWIN (RPH)
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:EDWIN
Last Name:CLAY
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 1:474 HIGHWAY 67 S
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-6300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:474 HIGHWAY 67 S
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-6300
Practice Address - Country:US
Practice Address - Phone:256-353-0100
Practice Address - Fax:256-353-0299
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002689Medicaid