Provider Demographics
NPI:1548750110
Name:CLARK, BENJAMIN ADDRIL (RPH)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ADDRIL
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:SE REGIONAL PHARMACY ATTN: BEN CLARK
Mailing Address - Street 2:300 FIRST AVENUE SOUTH
Mailing Address - City:REIDSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SE REGIONAL PHARMACY ATTN: BEN CLARK
Practice Address - Street 2:300 FIRST AVENUE SOUTH
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453
Practice Address - Country:US
Practice Address - Phone:912-557-7960
Practice Address - Fax:912-557-7975
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist