Provider Demographics
NPI:1154674398
Name:CLARKE, JOHN A (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CLARKE
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 1:4932 RACCOON VALLEY RD SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-9271
Mailing Address - Country:US
Mailing Address - Phone:253-312-1236
Mailing Address - Fax:
Practice Address - Street 1:4932 RACCOON VALLEY RD SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-9271
Practice Address - Country:US
Practice Address - Phone:253-312-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist