Provider Demographics
NPI:1760735328
Name:CLARK, DOUGLAS LEE
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-0050
Mailing Address - Country:US
Mailing Address - Phone:715-356-9449
Mailing Address - Fax:715-356-0011
Practice Address - Street 1:9750 HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9753
Practice Address - Country:US
Practice Address - Phone:715-356-9449
Practice Address - Fax:715-356-0011
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10717-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist