Provider Demographics
NPI:1205166238
Name:CLARK, ROGER (RPH)
Entity type:Individual
Prefix:
First Name:ROGER
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 1:19003 N R H JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-4402
Mailing Address - Country:US
Mailing Address - Phone:623-584-3000
Mailing Address - Fax:
Practice Address - Street 1:19003 N R H JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-4402
Practice Address - Country:US
Practice Address - Phone:623-584-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist