Provider Demographics
NPI:1801221650
Name:CLARK PHARMACY INC
Entity Type:Organization
Organization Name:CLARK PHARMACY INC
Other - Org Name:FULLERTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IL
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:773-887-4052
Mailing Address - Street 1:5305 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1424
Mailing Address - Country:US
Mailing Address - Phone:773-877-4052
Mailing Address - Fax:
Practice Address - Street 1:5305 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1424
Practice Address - Country:US
Practice Address - Phone:773-877-4052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.018328332B00000X
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies