Provider Demographics
NPI:1497125959
Name:CLARK'S SPECIALTY PHARMACY
Entity Type:Organization
Organization Name:CLARK'S SPECIALTY PHARMACY
Other - Org Name:BIG COUNTRY DERMATOLOGY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-773-5958
Mailing Address - Street 1:1229 RESERVE BLVD STE 100A
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-3273
Mailing Address - Country:US
Mailing Address - Phone:806-451-4799
Mailing Address - Fax:
Practice Address - Street 1:17 WINDMILL CIR STE B
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5234
Practice Address - Country:US
Practice Address - Phone:325-704-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30242333600000X
3336C0003X, 3336C0004X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153704OtherPK