Provider Demographics
NPI:1477172906
Name:CLEARK, KENYATTA (RPH, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KENYATTA
Middle Name:
Last Name:CLEARK
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 MOORES CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2923
Mailing Address - Country:US
Mailing Address - Phone:769-251-3601
Mailing Address - Fax:
Practice Address - Street 1:1522 MOORES CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-2923
Practice Address - Country:US
Practice Address - Phone:769-251-3601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist