Provider Demographics
NPI:1255960415
Name:CLARK, RANDALL LEWIS (R PH)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEWIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 FREDONIA RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-9755
Mailing Address - Country:US
Mailing Address - Phone:724-301-6641
Mailing Address - Fax:
Practice Address - Street 1:43 WILLIAMSON RD STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1224
Practice Address - Country:US
Practice Address - Phone:724-373-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP030549L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist