Provider Demographics
NPI:1578159448
Name:CLARK, MARY LISA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LISA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 LITTLE HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:PHILPOT
Mailing Address - State:KY
Mailing Address - Zip Code:42366-9046
Mailing Address - Country:US
Mailing Address - Phone:270-314-7899
Mailing Address - Fax:
Practice Address - Street 1:3311 HWY 54
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2120
Practice Address - Country:US
Practice Address - Phone:270-926-0476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist