Provider Demographics
NPI:1063639995
Name:CLARK, JOHN C (PHARM D)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1176
Mailing Address - Country:US
Mailing Address - Phone:973-667-4904
Mailing Address - Fax:
Practice Address - Street 1:5 REGENT ST
Practice Address - Street 2:SUITE 506
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-1675
Practice Address - Country:US
Practice Address - Phone:800-552-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03106100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist