Provider Demographics
NPI:1780703520
Name:CLARK, KELLY DAWN (RPH)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DAWN
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 1:3405 COUNTRY BEND PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6155
Mailing Address - Country:US
Mailing Address - Phone:217-355-9363
Mailing Address - Fax:
Practice Address - Street 1:1802 S MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5923
Practice Address - Country:US
Practice Address - Phone:217-326-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist