MEDICARE: DR. DEIDRE CLARK PHARMD, BCPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1200X	Pharmacotherapy Pharmacist	14570	AL

General Provider Information

NPI Number	:	1881690832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEIDRE CLARK PHARMD, BCPS

Provider Business Mailing Address
First Line	:	1700 COLLIER WAY
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35405-6104
Country	:	US
Telephone Number	:	205-752-8802
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 LOOP RD
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35404-5015
Country	:	US
Telephone Number	:	205-554-2000
Fax Number	:	205-554-2868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/08/2007

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