Provider Demographics
NPI:1336606649
Name:CLARK, CRYSTAL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:223 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-3501
Mailing Address - Country:US
Mailing Address - Phone:410-638-0600
Mailing Address - Fax:410-638-6469
Practice Address - Street 1:223 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3501
Practice Address - Country:US
Practice Address - Phone:410-638-0600
Practice Address - Fax:410-638-6469
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21567183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist