Provider Demographics
NPI:1154331890
Name:CLARK, KAREN S
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:S
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 1:12 FISHER AVE
Mailing Address - Street 2:APT # 3
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3382
Mailing Address - Country:US
Mailing Address - Phone:617-909-3590
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:MENINO PAVILLION
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-4883
Practice Address - Fax:617-414-6628
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5985183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician