=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720866742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYDNEY APRIL CLARK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2023
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 W 6TH ST
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-558-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 BLACK CIR
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-551-8298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 34559
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------