Healthcare Provider Details

I. General information

NPI: 1891792891
Provider Name (Legal Business Name): TERRY CLARK THOMAS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11042 SR 525 SUITE 130
CLINTON WA
98236-8618
US

IV. Provider business mailing address

5823 BOB GALBREATH RD PO BOX 946
CLINTON WA
98236-9558
US

V. Phone/Fax

Practice location:
  • Phone: 360-341-3885
  • Fax: 360-341-3886
Mailing address:
  • Phone: 360-341-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00021826
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: