MEDICARE: MR. JOHN C CLARK PHARM D

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	28RI03106100	NJ

General Provider Information

NPI Number	:	1063639995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN C CLARK PHARM D

Provider Business Mailing Address
First Line	:	173 HIGH ST
Second Line	:
City	:	NUTLEY
State	:	NJ
Zip	:	07110-1176
Country	:	US
Telephone Number	:	973-667-4904
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 REGENT ST
Second Line	:	SUITE 506
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-1675
Country	:	US
Telephone Number	:	800-552-3461
Fax Number	:

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

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	07/08/2007

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