1003500752 NPI number — LENLOCK RX, LLC DBA CLEBURNE PHARMACY

Table of content: MS. GAYLE RENEE LABISSONIERE LMFT (NPI 1053448183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003500752 NPI number — LENLOCK RX, LLC DBA CLEBURNE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LENLOCK RX, LLC DBA CLEBURNE PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003500752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 BILL ROBISON PKWY STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNISTON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36206-2624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-444-6282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 BILL ROBISON PKWY STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNISTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36206-2624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-444-6282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
TANT
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-680-1997

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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