Provider Demographics
NPI:1821685157
Name:CLARK, TONY DALE
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:DALE
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 1:6552 BARTH RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-3510
Mailing Address - Country:US
Mailing Address - Phone:913-669-3091
Mailing Address - Fax:
Practice Address - Street 1:12200 W 95TH ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-3806
Practice Address - Country:US
Practice Address - Phone:913-894-2093
Practice Address - Fax:913-894-8167
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-15358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist