Provider Demographics
NPI:1114263241
Name:CLARK, ROBERT D (R PH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 N KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3638
Mailing Address - Country:US
Mailing Address - Phone:843-626-2295
Mailing Address - Fax:
Practice Address - Street 1:1403 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3638
Practice Address - Country:US
Practice Address - Phone:843-626-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist