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General NPI Number Information
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NPI Number | 1669785697
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Entity Type | Individual
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Provider Name | CLARK KEBODEAUX PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2010
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 4218 LINDELL BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63108-2916
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Country | US
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Telephone | 314-534-3829
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Fax |
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Provider Business Mailing Address
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Address Line | 4588 PARKVIEW PL
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City | SAINT LOUIS
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State | MO
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Zip | 63110-1029
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Country | US
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Telephone | 314-446-8508
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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 | 015036
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2011021859
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License Number State | MO
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