Healthcare Provider Details

I. General information

NPI: 1992885461
Provider Name (Legal Business Name): CLARK'S RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W MARKET ST
LIMA OH
45801-4601
US

IV. Provider business mailing address

701 W MARKET ST
LIMA OH
45801-4601
US

V. Phone/Fax

Practice location:
  • Phone: 419-223-8906
  • Fax: 419-222-1619
Mailing address:
  • Phone: 419-223-8906
  • Fax: 419-222-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRTP02014460003
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0337451
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier2072874
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: TIM RICHARD CLARK
Title or Position: OWNER/PRESIDENT
Credential: RPH
Phone: 419-223-8906