Provider Demographics
NPI:1225404791
Name:CLARK, BRUCE EDWARD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35300 HIGHWAY 41
Mailing Address - Street 2:STE 101
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-8715
Mailing Address - Country:US
Mailing Address - Phone:888-249-8884
Mailing Address - Fax:
Practice Address - Street 1:35300 HIGHWAY 41
Practice Address - Street 2:STE 101
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-8715
Practice Address - Country:US
Practice Address - Phone:888-249-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 30899183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy