Provider Demographics
NPI:1770146243
Name:CLARK, KATHERINE T (PHARMD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E DOUGLAS RD STE 406
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1468
Mailing Address - Country:US
Mailing Address - Phone:574-335-7074
Mailing Address - Fax:
Practice Address - Street 1:60101 BODNAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-9328
Practice Address - Country:US
Practice Address - Phone:574-335-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027104A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist