Provider Demographics
NPI:1689251423
Name:CLARK, LEXUS
Entity Type:Individual
Prefix:
First Name:LEXUS
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-6631
Mailing Address - Country:US
Mailing Address - Phone:804-253-0759
Mailing Address - Fax:804-253-9788
Practice Address - Street 1:5700 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-6631
Practice Address - Country:US
Practice Address - Phone:804-253-0759
Practice Address - Fax:804-253-9788
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230031423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist