Provider Demographics
NPI:1588650733
Name:CLARK, BETH ELLEN (PHARMD, CACP)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD, CACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10366 OLD FREDERICK RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1309
Mailing Address - Country:US
Mailing Address - Phone:410-590-4140
Mailing Address - Fax:410-590-4159
Practice Address - Street 1:808 LANDMARK DR
Practice Address - Street 2:SUITE 128
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4983
Practice Address - Country:US
Practice Address - Phone:410-590-4140
Practice Address - Fax:410-590-4159
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist