Provider Demographics
NPI:1427163625
Name:CLARK PHARMACY LLC
Entity type:Organization
Organization Name:CLARK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GINGRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-232-3940
Mailing Address - Street 1:1316 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3531
Mailing Address - Country:US
Mailing Address - Phone:281-232-3940
Mailing Address - Fax:832-595-1203
Practice Address - Street 1:502 W MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-8827
Practice Address - Country:US
Practice Address - Phone:936-856-4594
Practice Address - Fax:936-856-3512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFECHEK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX241893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4510687OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX140591Medicaid
4510687OtherNCPDP PROVIDER IDENTIFICATION NUMBER