Provider Demographics
NPI:1932439346
Name:CLARK, JOHN BRUCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRUCE
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 CAMBROOK CT
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8488
Mailing Address - Country:US
Mailing Address - Phone:719-481-0021
Mailing Address - Fax:
Practice Address - Street 1:1150 CAMBROOK CT
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8488
Practice Address - Country:US
Practice Address - Phone:719-481-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO113221835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist