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General NPI Number Information
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NPI Number | 1104476225
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Entity Type | Individual
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Provider Name | ROGER KEVIN CLARK JR. PHARMD
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Gender | Male
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Dates
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Enumeration Date | 09/19/2019
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Last Update Date | 09/19/2019
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Provider Practice Location Address
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Address Line | 3181 SW SAM JACKSON PARK RD
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City | PORTLAND
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State | OR
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Zip | 97239-3011
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Country | US
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Telephone | 503-418-3308
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Fax |
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Provider Business Mailing Address
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Address Line | 31192 SW WILLAMETTE WAY W
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City | WILSONVILLE
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State | OR
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Zip | 97070-8581
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Country | US
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Telephone | 503-570-3436
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0011422
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License Number State | OR
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