Provider Demographics
NPI:1275976276
Name:CLARK, KEVIN P (RPH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SIXTH STREET
Mailing Address - Street 2:PO BOX 928
Mailing Address - City:HOTCHKISS
Mailing Address - State:CO
Mailing Address - Zip Code:81419-0928
Mailing Address - Country:US
Mailing Address - Phone:970-872-2623
Mailing Address - Fax:670-872-2635
Practice Address - Street 1:215 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:HOTCHKISS
Practice Address - State:CO
Practice Address - Zip Code:81419-0928
Practice Address - Country:US
Practice Address - Phone:970-872-2623
Practice Address - Fax:670-872-2635
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist