Provider Demographics
NPI:1851613210
Name:CLARK PHARMACY LLC
Entity Type:Organization
Organization Name:CLARK PHARMACY LLC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GINGRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-232-3940
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537
Mailing Address - Country:US
Mailing Address - Phone:956-461-2400
Mailing Address - Fax:956-461-2412
Practice Address - Street 1:701 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-2765
Practice Address - Country:US
Practice Address - Phone:956-461-2400
Practice Address - Fax:956-461-2412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFECHEK AUCHAN PARTNERS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-25
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX268993336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144609OtherPK
TX146146Medicaid
4555441OtherNCPDP PROVIDER IDENTIFICATION NUMBER