Provider Demographics
NPI:1972371334
Name:CLARK, JONATHAN DANIEL (PHARMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
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 1:809 WALROSE CIR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-9196
Mailing Address - Country:US
Mailing Address - Phone:918-704-5377
Mailing Address - Fax:
Practice Address - Street 1:420 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5246
Practice Address - Country:US
Practice Address - Phone:501-801-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist