MEDICARE: KERRY MCCRAE CLARK PHARMD

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	20054475	NY

General Provider Information

NPI Number	:	1306159983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY MCCRAE CLARK PHARMD

Provider Business Mailing Address
First Line	:	1917 ROUTE 19
Second Line	:
City	:	WELLSVILLE
State	:	NY
Zip	:	14895-9740
Country	:	US
Telephone Number	:	585-593-5754
Fax Number	:	585-593-5754

Provider Business Practice Location Address
First Line	:	36 N MAIN ST
Second Line	:
City	:	ALFRED
State	:	NY
Zip	:	14802-1011
Country	:	US
Telephone Number	:	607-587-9222
Fax Number	:	607-587-9629

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

Provider Enumeration Date	:	07/23/2010
Last Update Date	:	07/23/2010

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