Provider Demographics
NPI:1043514540
Name:CLARK, GARY D (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9146
Mailing Address - Country:US
Mailing Address - Phone:704-878-0665
Mailing Address - Fax:704-500-2350
Practice Address - Street 1:2701 S NC 127 HWY
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9130
Practice Address - Country:US
Practice Address - Phone:828-294-1644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist