Provider Demographics
NPI:1265733489
Name:CLARK, CHRISTINA LYNN (RPH)
Entity type:Individual
Prefix:MR
First Name:CHRISTINA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21301 HWY 410 EAST
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391
Mailing Address - Country:US
Mailing Address - Phone:253-862-2533
Mailing Address - Fax:
Practice Address - Street 1:21301 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8468
Practice Address - Country:US
Practice Address - Phone:253-862-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00020225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist