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General NPI Number Information
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NPI Number | 1689826984
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Entity Type | Individual
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Provider Name | CHARLES JOHN CLARK R.PH.
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Gender | Male
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Dates
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Enumeration Date | 10/17/2008
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Last Update Date | 10/17/2008
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Provider Practice Location Address
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Address Line | 203 SO. DAISY
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City | SALMON
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State | ID
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Zip | 83467
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Country | US
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Telephone | 208-756-5672
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Fax | 208-756-5757
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Provider Business Mailing Address
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Address Line | BOX 700 STEELE MEMORIAL MEDICAL CENTER 203 SO. DAISY
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City | SALMON
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State | ID
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Zip | 83467
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Country | US
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Telephone | 208-756-5672
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Fax | 208-756-5757
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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 | P-4334
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License Number State | ID
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