Provider Demographics
NPI:1346406782
Name:CLARK, STEPHANIE (D PH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:D PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 47TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75462-3173
Mailing Address - Country:US
Mailing Address - Phone:903-737-8404
Mailing Address - Fax:903-785-5657
Practice Address - Street 1:931 S COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-6307
Practice Address - Country:US
Practice Address - Phone:903-785-5656
Practice Address - Fax:903-785-5657
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist