Provider Demographics
NPI:1942520291
Name:CLARK, TIA C (RPH)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S SOSSAMAN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2001
Mailing Address - Country:US
Mailing Address - Phone:480-325-4777
Mailing Address - Fax:480-325-4544
Practice Address - Street 1:420 S SOSSAMAN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2001
Practice Address - Country:US
Practice Address - Phone:480-985-3658
Practice Address - Fax:480-985-4718
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS010558183500000X
AZ10558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist