Provider Demographics
NPI:1184912883
Name:CLARK, JASON (RPH)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
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 1:552 VERDAE DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5384
Mailing Address - Country:US
Mailing Address - Phone:864-237-2099
Mailing Address - Fax:
Practice Address - Street 1:3021 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5643
Practice Address - Country:US
Practice Address - Phone:864-576-9201
Practice Address - Fax:864-576-6584
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC009365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009365OtherPHARMACIST