Provider Demographics
NPI:1326321811
Name:CLARK, BENJAMIN PAUL (PHARMD, MPA)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:PAUL
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8457 STILLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WHITESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42378-9582
Mailing Address - Country:US
Mailing Address - Phone:270-686-7873
Mailing Address - Fax:
Practice Address - Street 1:2318 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4826
Practice Address - Country:US
Practice Address - Phone:270-686-7873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015052183500000X
IN26023978A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist