Provider Demographics
NPI:1003211053
Name:CLARK, DESSIE (RPH)
Entity Type:Individual
Prefix:
First Name:DESSIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 PRIVATE LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-8114
Mailing Address - Country:US
Mailing Address - Phone:252-937-2284
Mailing Address - Fax:
Practice Address - Street 1:261 PRIVATE LN
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-8114
Practice Address - Country:US
Practice Address - Phone:252-937-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11021979OtherMEDICARE