Provider Demographics
NPI:1225643521
Name:CLARK, JARED WILLIAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:WILLIAM
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 1:602 RAY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAY
Mailing Address - State:TX
Mailing Address - Zip Code:76366-3855
Mailing Address - Country:US
Mailing Address - Phone:940-613-1200
Mailing Address - Fax:
Practice Address - Street 1:602 RAY RD
Practice Address - Street 2:
Practice Address - City:HOLLIDAY
Practice Address - State:TX
Practice Address - Zip Code:76366-3855
Practice Address - Country:US
Practice Address - Phone:940-613-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist