Provider Demographics
NPI:1740870732
Name:CLARK, MADELYNN BREANNA
Entity type:Individual
Prefix:
First Name:MADELYNN
Middle Name:BREANNA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-7927
Mailing Address - Country:US
Mailing Address - Phone:512-619-4636
Mailing Address - Fax:
Practice Address - Street 1:5000 GATTIS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-2025
Practice Address - Country:US
Practice Address - Phone:512-251-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX270963183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician