Provider Demographics
NPI:1366042566
Name:CLARK, TANYA RAY (RPH)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 CASCADE LN
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-5504
Mailing Address - Country:US
Mailing Address - Phone:479-721-9267
Mailing Address - Fax:
Practice Address - Street 1:3500 SE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5182
Practice Address - Country:US
Practice Address - Phone:479-621-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist