Provider Demographics
NPI:1639884521
Name:CLARK, LEWIS WAYNE FORREST (RPH)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:WAYNE FORREST
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 1:115 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4721
Mailing Address - Country:US
Mailing Address - Phone:580-225-4418
Mailing Address - Fax:580-225-4415
Practice Address - Street 1:115 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4721
Practice Address - Country:US
Practice Address - Phone:580-225-4418
Practice Address - Fax:580-225-4415
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist