Healthcare Provider Details

I. General information

NPI: 1134634587
Provider Name (Legal Business Name): CLARK MELVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8730 WATERVILLE SWANTON RD
WATERVILLE OH
43566-9726
US

IV. Provider business mailing address

4337 MOSER LN
PERRYSBURG OH
43551-7188
US

V. Phone/Fax

Practice location:
  • Phone: 419-878-1040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03237275
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: