Provider Demographics
NPI:1689989493
Name:CLARK, ELIZABETH ANN (RPH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2601 S NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-2200
Mailing Address - Country:US
Mailing Address - Phone:704-854-4702
Mailing Address - Fax:704-868-2690
Practice Address - Street 1:12830 WALKER BRANCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-8850
Practice Address - Country:US
Practice Address - Phone:704-583-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8337183500000X
NC12246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist