Provider Demographics
NPI:1508403726
Name:CLARK, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4672 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3805
Mailing Address - Country:US
Mailing Address - Phone:989-921-6222
Mailing Address - Fax:989-921-6225
Practice Address - Street 1:4672 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3805
Practice Address - Country:US
Practice Address - Phone:989-921-6222
Practice Address - Fax:989-921-6225
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53026907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist