Provider Demographics
NPI:1508948480
Name:CLARK, JOHN JOSEPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:MCCOOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-2206
Mailing Address - Country:US
Mailing Address - Phone:308-345-4594
Mailing Address - Fax:
Practice Address - Street 1:205 NORRIS AVE
Practice Address - Street 2:
Practice Address - City:MCCOOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3704
Practice Address - Country:US
Practice Address - Phone:308-345-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist