Provider Demographics
NPI:1437458692
Name:CLARK, TIMOTHY ALLEN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
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 1:1683 E GRULER RD
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8821
Mailing Address - Country:US
Mailing Address - Phone:231-347-6269
Mailing Address - Fax:
Practice Address - Street 1:250 S LAKE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9376
Practice Address - Country:US
Practice Address - Phone:231-536-0901
Practice Address - Fax:231-536-3284
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist