Provider Demographics
NPI:1669785697
Name:KEBODEAUX, CLARK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:
Last Name:KEBODEAUX
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4588 PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1029
Mailing Address - Country:US
Mailing Address - Phone:314-446-8508
Mailing Address - Fax:
Practice Address - Street 1:4218 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2916
Practice Address - Country:US
Practice Address - Phone:314-534-3829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015036183500000X
MO2011021859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist