Provider Demographics
NPI:1154753341
Name:CLARK, THOMAS (RPH,MBA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-2732
Mailing Address - Country:US
Mailing Address - Phone:913-651-7455
Mailing Address - Fax:913-682-4220
Practice Address - Street 1:429 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-2732
Practice Address - Country:US
Practice Address - Phone:913-651-7455
Practice Address - Fax:913-682-4220
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-09492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist