Provider Demographics
NPI:1871653766
Name:CLARK, ROSS WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:WILLIAM
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1697A HWY A.1.A.
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:LA
Mailing Address - Zip Code:32937
Mailing Address - Country:US
Mailing Address - Phone:321-917-7323
Mailing Address - Fax:
Practice Address - Street 1:7025 N WICKHAM RD
Practice Address - Street 2:SUITE 113
Practice Address - City:MELBOURNE
Practice Address - State:LA
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-253-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0025442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS0025442OtherPHARMACY LICENSE