Provider Demographics
NPI:1689826984
Name:CLARK, CHARLES JOHN (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOHN
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:BOX 700
Mailing Address - Street 2:STEELE MEMORIAL MEDICAL CENTER 203 SO. DAISY
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467
Mailing Address - Country:US
Mailing Address - Phone:208-756-5672
Mailing Address - Fax:208-756-5757
Practice Address - Street 1:203 SO. DAISY
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467
Practice Address - Country:US
Practice Address - Phone:208-756-5672
Practice Address - Fax:208-756-5757
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-4334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist