Provider Demographics
NPI:1811412109
Name:CLARK, LATOYA SHANEESE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:SHANEESE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 OBSERVATION CIR UNIT 301
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1687
Mailing Address - Country:US
Mailing Address - Phone:731-618-1911
Mailing Address - Fax:
Practice Address - Street 1:7700 SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4021
Practice Address - Country:US
Practice Address - Phone:502-968-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist