Provider Demographics
NPI:1922602275
Name:CLARK, ANTHONY CHARLES SR
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:CHARLES
Last Name:CLARK
Suffix:SR
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 1:9167 STAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2027
Mailing Address - Country:US
Mailing Address - Phone:804-672-6613
Mailing Address - Fax:
Practice Address - Street 1:9167 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2027
Practice Address - Country:US
Practice Address - Phone:804-672-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist