Provider Demographics
NPI:1972886042
Name:CLARK, LAURA (PHARMD, LAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 LAKE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3553
Mailing Address - Country:US
Mailing Address - Phone:719-900-3009
Mailing Address - Fax:
Practice Address - Street 1:2860 S CIRCLE DR STE 250
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4132
Practice Address - Country:US
Practice Address - Phone:719-900-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU0002363171100000X
FLPS41015183500000X
COPHA.0022073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No183500000XPharmacy Service ProvidersPharmacist