Provider Demographics
NPI:1518547975
Name:CLARK, HEATHER LEE LOUISE (CPHT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 OLD HIGHWAY 58 LOT 18
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37336-6264
Mailing Address - Country:US
Mailing Address - Phone:423-827-8625
Mailing Address - Fax:
Practice Address - Street 1:3000 OLD HIGHWAY 58 LOT 18
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TN
Practice Address - Zip Code:37336-6264
Practice Address - Country:US
Practice Address - Phone:423-827-8625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183700000X
TN40866183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician