Provider Demographics
NPI:1861014656
Name:HART, CLIFFORD WAYNE
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:WAYNE
Last Name:HART
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 1:55 JOHN F KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-5309
Mailing Address - Country:US
Mailing Address - Phone:563-556-3705
Mailing Address - Fax:563-556-2616
Practice Address - Street 1:55 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-5309
Practice Address - Country:US
Practice Address - Phone:563-556-3705
Practice Address - Fax:563-556-2616
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist