Provider Demographics
NPI:1689950479
Name:CLARK, STACY (RPH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52482 STATE ROAD 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3852
Mailing Address - Country:US
Mailing Address - Phone:574-271-0357
Mailing Address - Fax:
Practice Address - Street 1:52482 STATE ROAD 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3852
Practice Address - Country:US
Practice Address - Phone:574-271-0357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026870183500000X
IN26016810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist