Provider Demographics
NPI:1124420260
Name:CLARK, TIMOTHY HALL (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:HALL
Last Name:CLARK
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 1:295 PINEHURST AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7051
Mailing Address - Country:US
Mailing Address - Phone:910-246-5155
Mailing Address - Fax:910-246-5157
Practice Address - Street 1:295 PINEHURST AVE
Practice Address - Street 2:STE 2
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7051
Practice Address - Country:US
Practice Address - Phone:910-246-5155
Practice Address - Fax:910-246-5157
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist