Provider Demographics
NPI:1114987575
Name:CLARK, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 1ST ST E
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1422
Practice Address - Country:US
Practice Address - Phone:319-895-6248
Practice Address - Fax:319-895-6991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist