Provider Demographics
NPI:1992885461
Name:CLARK'S RX LLC
Entity type:Organization
Organization Name:CLARK'S RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-223-8906
Mailing Address - Street 1:701 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4601
Mailing Address - Country:US
Mailing Address - Phone:419-223-8906
Mailing Address - Fax:419-222-1619
Practice Address - Street 1:701 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4601
Practice Address - Country:US
Practice Address - Phone:419-223-8906
Practice Address - Fax:419-222-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRTP020144600033336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337451Medicaid
2072874OtherPK
0283280001Medicare NSC