Healthcare Provider Details

I. General information

NPI: 1679499248
Provider Name (Legal Business Name): CARSON CLARKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26031989A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: