Provider Demographics
NPI:1659856185
Name:CLARK, MARK WAYNE (DBA MARION FAMILY)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DBA MARION FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 BLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1956
Mailing Address - Country:US
Mailing Address - Phone:870-739-1111
Mailing Address - Fax:870-739-1116
Practice Address - Street 1:134 BLOCK ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1956
Practice Address - Country:US
Practice Address - Phone:870-739-1111
Practice Address - Fax:870-739-1116
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR208953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0426355OtherNCPDP