Provider Demographics
NPI:1558495317
Name:CLARK, TOM H (RPH)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:H
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 1:614-112 RED OAK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-6344
Mailing Address - Country:US
Mailing Address - Phone:407-754-6059
Mailing Address - Fax:
Practice Address - Street 1:614-112 RED OAK CIRCLE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-6344
Practice Address - Country:US
Practice Address - Phone:407-754-6059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist