Provider Demographics
NPI:1619222932
Name:CLARK, KRISTIE DAWN (PHARMD, CDE)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK DR
Mailing Address - Street 2:STE 550
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2982
Mailing Address - Country:US
Mailing Address - Phone:704-403-1307
Mailing Address - Fax:704-403-3655
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 550
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-1307
Practice Address - Fax:704-403-3655
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172991835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist