Provider Demographics
NPI:1255472874
Name:CLARK, MARK ELDON
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELDON
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15615 BEL RED RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15615 BEL RED RD
Practice Address - Street 2:SUITE B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-2300
Practice Address - Country:US
Practice Address - Phone:425-881-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist