Provider Demographics
NPI:1285732503
Name:CLARK'S PHARMACY, INC
Entity type:Organization
Organization Name:CLARK'S PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:R.PH. / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:319-393-3210
Mailing Address - Street 1:1946 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3041
Mailing Address - Country:US
Mailing Address - Phone:319-393-3210
Mailing Address - Fax:319-393-2747
Practice Address - Street 1:1946 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3041
Practice Address - Country:US
Practice Address - Phone:319-393-3210
Practice Address - Fax:319-393-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0133439Medicaid
IA0684550001Medicare NSC
IA0684550001Medicare ID - Type Unspecified