Provider Demographics
NPI:1093849879
Name:CLARK, DONNA LEE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:LEE
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:PO BOX 33 JEWEL STREET
Mailing Address - Street 2:PROCTOR BOTTOM
Mailing Address - City:AMHERSTDALE
Mailing Address - State:WV
Mailing Address - Zip Code:25607
Mailing Address - Country:US
Mailing Address - Phone:304-583-7184
Mailing Address - Fax:304-583-9929
Practice Address - Street 1:124 MAIN ST
Practice Address - Street 2:MAN PHARMACY
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1212
Practice Address - Country:US
Practice Address - Phone:304-583-9910
Practice Address - Fax:304-583-9929
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist