Provider Demographics
NPI:1245221324
Name:CLARK, TERRY ROBERT (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:ROBERT
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17741 MANASTASH RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9119
Mailing Address - Country:US
Mailing Address - Phone:509-962-2812
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE STE E127
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:509-899-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH00010513OtherLICENSE
WAPH00010513OtherLICENSE