MEDICARE: CLARK PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	24189	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4510687	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427163625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK PHARMACY LLC

Provider Business Mailing Address
First Line	:	1316 7TH ST
Second Line	:
City	:	ROSENBERG
State	:	TX
Zip	:	77471-3531
Country	:	US
Telephone Number	:	281-232-3940
Fax Number	:	832-595-1203

Provider Business Practice Location Address
First Line	:	502 W MONTGOMERY ST
Second Line	:
City	:	WILLIS
State	:	TX
Zip	:	77378-8827
Country	:	US
Telephone Number	:	936-856-4594
Fax Number	:	936-856-3512

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	BRUCE GINGRICH
Credential	:
Telephone Number	:	281-232-3940

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	03/30/2011

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Directions to “CLARK PHARMACY LLC ” Practice Location

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