Provider Demographics
NPI:1760951586
Name:CLARK, LAUREN MARILYN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARILYN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08848-1213
Mailing Address - Country:US
Mailing Address - Phone:609-213-3243
Mailing Address - Fax:
Practice Address - Street 1:36 WATER ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:08848-1213
Practice Address - Country:US
Practice Address - Phone:609-213-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03785300183500000X
PARP448880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist