MEDICARE: MR. GARY D CLARK R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	12024	NC

General Provider Information

NPI Number	:	1043514540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY D CLARK R.PH.

Provider Business Mailing Address
First Line	:	125 NORTHFIELD RD
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28625-9146
Country	:	US
Telephone Number	:	704-878-0665
Fax Number	:	704-500-2350

Provider Business Practice Location Address
First Line	:	2701 S NC 127 HWY
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28602-9130
Country	:	US
Telephone Number	:	828-294-1644
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2010
Last Update Date	:	03/07/2011

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