Provider Demographics
NPI:1750629267
Name:CLARK, DENNIS RAY (RPH)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:RAY
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 1:162 NE BEACON DR
Mailing Address - Street 2:SUITE #109
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-4260
Mailing Address - Country:US
Mailing Address - Phone:541-474-3784
Mailing Address - Fax:
Practice Address - Street 1:162 NE BEACON DR
Practice Address - Street 2:SUITE #109
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-4260
Practice Address - Country:US
Practice Address - Phone:541-474-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7947183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist