Provider Demographics
NPI:1164746442
Name:CLARK, GLYNIS PRICE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:GLYNIS
Middle Name:PRICE
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 1:31 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-2518
Mailing Address - Country:US
Mailing Address - Phone:315-635-3155
Mailing Address - Fax:
Practice Address - Street 1:31 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-2518
Practice Address - Country:US
Practice Address - Phone:315-635-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist