Provider Demographics
NPI:1003965765
Name:CLARK, DIAHN L (PHARMD, JD)
Entity Type:Individual
Prefix:
First Name:DIAHN
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025 N WICKHAM RD
Mailing Address - Street 2:SUITE 113B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7534
Mailing Address - Country:US
Mailing Address - Phone:321-253-3535
Mailing Address - Fax:321-253-2522
Practice Address - Street 1:7025 N WICKHAM RD
Practice Address - Street 2:SUITE 113B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7534
Practice Address - Country:US
Practice Address - Phone:321-253-3535
Practice Address - Fax:321-253-2522
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0028636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist