Provider Demographics
NPI:1780999748
Name:CLARK, MITZI (RPH)
Entity type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:
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 1:6520 FRATT RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-4402
Mailing Address - Country:US
Mailing Address - Phone:210-938-4536
Mailing Address - Fax:210-938-4571
Practice Address - Street 1:6520 FRATT RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-4402
Practice Address - Country:US
Practice Address - Phone:210-938-4536
Practice Address - Fax:210-938-4571
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist