Provider Demographics
NPI:1861700874
Name:PADERICK, CLIFTON WALDO JR
Entity type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:WALDO
Last Name:PADERICK
Suffix:JR
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 1:3302 WINDMERE DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-7063
Mailing Address - Country:US
Mailing Address - Phone:919-776-0891
Mailing Address - Fax:
Practice Address - Street 1:3302 WINDMERE DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-7063
Practice Address - Country:US
Practice Address - Phone:919-776-0891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8775OtherNC PHARMACIST LICENSE