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General NPI Number Information
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NPI Number | 1639840911
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Entity Type | Individual
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Provider Name | MARY E CLARK CPHT
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Gender | Female
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Dates
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Enumeration Date | 09/25/2021
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Last Update Date | 09/25/2021
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Provider Practice Location Address
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Address Line | 1105 MICHIGAN AVE
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City | OROFINO
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State | ID
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Zip | 83544-9005
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Country | US
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Telephone | 208-476-3600
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Fax |
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Provider Business Mailing Address
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Address Line | 89 SUNNYSIDE BENCH RD
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City | LENORE
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State | ID
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Zip | 83541-5028
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Country | US
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Telephone | 208-451-6535
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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 | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | 30178781
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License Number State | ID
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