Provider Demographics
NPI:1659717353
Name:CLARK, MARY ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
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 1:130 W UPTON AVE
Mailing Address - Street 2:
Mailing Address - City:REED CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49677-1130
Mailing Address - Country:US
Mailing Address - Phone:231-832-3515
Mailing Address - Fax:231-832-4140
Practice Address - Street 1:130 W UPTON AVE
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-1307
Practice Address - Country:US
Practice Address - Phone:231-832-3515
Practice Address - Fax:231-832-4140
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist