Provider Demographics
NPI:1992472195
Name:CLARK, ELLIOTT CLINE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:CLINE
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 1:980 HOWELL MILL RD NW UNIT 419
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5959
Mailing Address - Country:US
Mailing Address - Phone:770-596-3777
Mailing Address - Fax:
Practice Address - Street 1:116 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2634
Practice Address - Country:US
Practice Address - Phone:770-887-5040
Practice Address - Fax:770-887-1699
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist