Provider Demographics
NPI:1700196979
Name:CLARK, ALEAH JOY (RPH)
Entity Type:Individual
Prefix:DR
First Name:ALEAH
Middle Name:JOY
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 1:291 W FERRY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1816
Mailing Address - Country:US
Mailing Address - Phone:716-882-6922
Mailing Address - Fax:
Practice Address - Street 1:291 W FERRY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1816
Practice Address - Country:US
Practice Address - Phone:716-882-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI055057-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI055057-1OtherIMMUNIZING PHARMACIST