Provider Demographics
NPI:1518259316
Name:CLARK, BROOKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:BUSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:6237 S 20TH GLN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6237 S 20TH GLN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5434
Practice Address - Country:US
Practice Address - Phone:602-770-2854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMIN0002854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist