Healthcare Provider Details

I. General information

NPI: 1366892549
Provider Name (Legal Business Name): ELIZABETH G CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 09/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MALLETT DR
TOPSHAM ME
04086-1300
US

IV. Provider business mailing address

77 MALLETT DR
TOPSHAM ME
04086-1300
US

V. Phone/Fax

Practice location:
  • Phone: 207-729-0806
  • Fax: 207-725-8293
Mailing address:
  • Phone: 207-729-0806
  • Fax: 207-725-8293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR46176
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number188647
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: