Provider Demographics
NPI:1427659705
Name:CLARK, ABIGAIL LOUISE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LONGVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-9551
Mailing Address - Country:US
Mailing Address - Phone:330-402-9759
Mailing Address - Fax:
Practice Address - Street 1:3551 N RIDGE EAST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4313
Practice Address - Country:US
Practice Address - Phone:440-998-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03338060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist