MEDICARE: MARY E CLARK CPHT

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	183700000X	Pharmacy Technician	30178781	ID

General Provider Information

NPI Number	:	1639840911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY E CLARK CPHT

Provider Business Mailing Address
First Line	:	89 SUNNYSIDE BENCH RD
Second Line	:
City	:	LENORE
State	:	ID
Zip	:	83541-5028
Country	:	US
Telephone Number	:	208-451-6535
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 MICHIGAN AVE
Second Line	:
City	:	OROFINO
State	:	ID
Zip	:	83544-9005
Country	:	US
Telephone Number	:	208-476-3600
Fax Number	:

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

Provider Enumeration Date	:	09/25/2021
Last Update Date	:	09/25/2021

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Directions to “ MARY E CLARK CPHT” Practice Location

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