=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740548056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM DALE CLARK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2012
-----------------------------------------------------
Last Update Date | 04/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 16TH ST
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80631-5154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-350-6820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 MUSCOVEY LN
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80534-4614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-871-1683
-----------------------------------------------------
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 | 18066
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------