Provider Demographics
NPI:1700312782
Name:CLARK, DIANA RAGAN
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:RAGAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:RAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 N WASHINGTON ST
Mailing Address - Street 2:PHARMACY
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N WASHINGTON ST
Practice Address - Street 2:PHARMACY
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4518
Practice Address - Country:US
Practice Address - Phone:703-237-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist