Provider Demographics
NPI:1699007807
Name:CLARK, GEORGE JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:JAMES
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 1:9338 215TH PL
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1712
Mailing Address - Country:US
Mailing Address - Phone:718-464-3081
Mailing Address - Fax:
Practice Address - Street 1:9338 215TH PL
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1712
Practice Address - Country:US
Practice Address - Phone:718-464-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist