Provider Demographics
NPI:1609521814
Name:CLARK, KIMBERLY CHRISTINE (CPHT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CHRISTINE
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:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:SULTAN
Mailing Address - State:WA
Mailing Address - Zip Code:98294-0006
Mailing Address - Country:US
Mailing Address - Phone:425-399-6389
Mailing Address - Fax:
Practice Address - Street 1:205 PINE AVE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2539
Practice Address - Country:US
Practice Address - Phone:360-563-0223
Practice Address - Fax:360-563-0418
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61186782183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician