Provider Demographics
NPI:1700487360
Name:CLARK, DANIEL
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-0123
Mailing Address - Country:US
Mailing Address - Phone:435-851-4382
Mailing Address - Fax:
Practice Address - Street 1:660 S 1750 W
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3071
Practice Address - Country:US
Practice Address - Phone:801-489-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8784111-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist