Healthcare Provider Details

I. General information

NPI: 1255628590
Provider Name (Legal Business Name): ASHLEY LOUISE CLARK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTHCARE DRIVE DAYTONA BEACH VA OUTPATIENT CLINIC
DAYTONA BEAC FL
32608-1135
US

IV. Provider business mailing address

140 ACKLINS CIR APT 110
DAYTONA BEACH FL
32119-9771
US

V. Phone/Fax

Practice location:
  • Phone: 352-379-6062
  • Fax:
Mailing address:
  • Phone: 386-323-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberPS46401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: