Provider Demographics
NPI:1770588550
Name:CLARK, MONICA DARICE (RPH)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:DARICE
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 1:13062 THRUSH STREET NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448
Mailing Address - Country:US
Mailing Address - Phone:763-862-0893
Mailing Address - Fax:
Practice Address - Street 1:100 MONROE STREET
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-421-5540
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1171860OtherMN BOARD OF PHARMACY