MEDICARE: DR. JENNIFER 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	26023540A	IN
2	183500000X	Pharmacist	RPH60025	CA

General Provider Information

NPI Number	:	1588948764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER CLARK PHARM.D

Provider Business Mailing Address
First Line	:	1215 S RANGE LINE RD
Second Line	:
City	:	CARMEL
State	:	IN
Zip	:	46032-2519
Country	:	US
Telephone Number	:	317-571-1176
Fax Number	:	317-575-0037

Provider Business Practice Location Address
First Line	:	1215 S RANGE LINE RD
Second Line	:
City	:	CARMEL
State	:	IN
Zip	:	46032-2519
Country	:	US
Telephone Number	:	317-571-1176
Fax Number	:	317-575-0037

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

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	10/05/2011

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