Provider Demographics
NPI:1336220664
Name:CLARK, DONALD DALE (RPH)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:DALE
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 1:2305 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-3920
Mailing Address - Country:US
Mailing Address - Phone:270-796-3909
Mailing Address - Fax:270-796-4111
Practice Address - Street 1:2305 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3920
Practice Address - Country:US
Practice Address - Phone:270-796-3909
Practice Address - Fax:270-796-4111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist