Provider Demographics
NPI:1699056028
Name:CLARK, JACE ANTHONY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACE
Middle Name:ANTHONY
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W THOMAS RD STE 190
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4237
Mailing Address - Country:US
Mailing Address - Phone:602-406-3970
Mailing Address - Fax:602-406-7145
Practice Address - Street 1:500 W THOMAS RD STE 190
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4237
Practice Address - Country:US
Practice Address - Phone:602-406-3970
Practice Address - Fax:602-406-7145
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist