Healthcare Provider Details

I. General information

NPI: 1720145105
Provider Name (Legal Business Name): CLARK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MAIN ST
CIMARRON KS
67835-9998
US

IV. Provider business mailing address

PO BOX 207
CIMARRON KS
67835
US

V. Phone/Fax

Practice location:
  • Phone: 620-855-2242
  • Fax: 620-855-3616
Mailing address:
  • Phone: 620-855-2242
  • Fax: 620-855-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number209276
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAMES COAST
Title or Position: OWNER
Credential: RPH CGP
Phone: 620-855-2242