Provider Demographics
NPI:1649734310
Name:CLARK, CAROL RILEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:RILEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:EARLE
Mailing Address - State:AR
Mailing Address - Zip Code:72331-1616
Mailing Address - Country:US
Mailing Address - Phone:870-792-7177
Mailing Address - Fax:
Practice Address - Street 1:621 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:EARLE
Practice Address - State:AR
Practice Address - Zip Code:72331-1616
Practice Address - Country:US
Practice Address - Phone:870-792-7177
Practice Address - Fax:870-792-9005
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist