Provider Demographics
NPI:1952864233
Name:CLARK'S PHARMACY, INC
Entity Type:Organization
Organization Name:CLARK'S PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:319-393-3210
Mailing Address - Street 1:1946 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3041
Mailing Address - Country:US
Mailing Address - Phone:319-393-3210
Mailing Address - Fax:
Practice Address - Street 1:1946 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3041
Practice Address - Country:US
Practice Address - Phone:319-393-3210
Practice Address - Fax:319-393-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0133439Medicaid