Provider Demographics
NPI:1619057833
Name:ASTIN, CLARK THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:THOMAS
Last Name:ASTIN
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 1:241 BILLY DYAR BLVD
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-7102
Mailing Address - Country:US
Mailing Address - Phone:256-840-1100
Mailing Address - Fax:256-840-1119
Practice Address - Street 1:241 BILLY DYAR BLVD
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-7102
Practice Address - Country:US
Practice Address - Phone:256-840-1100
Practice Address - Fax:256-840-1119
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003516Medicaid