Provider Demographics
NPI:1336384437
Name:IMPERIOSO, CLARK EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:EDWARD
Last Name:IMPERIOSO
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 1:10 INDUSTRIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-3610
Mailing Address - Country:US
Mailing Address - Phone:978-244-1301
Mailing Address - Fax:
Practice Address - Street 1:10 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3610
Practice Address - Country:US
Practice Address - Phone:978-244-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist