MEDICARE: CLARKS RX 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	3336C0003X	Community/Retail Pharmacy	022177150	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3680142	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1710257902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKS RX LLC

Provider Business Mailing Address
First Line	:	7060 SOLUTIONS CENTER DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-0001
Country	:	US
Telephone Number	:	937-428-7970
Fax Number	:	937-428-7978

Provider Business Practice Location Address
First Line	:	9749 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45242-7207
Country	:	US
Telephone Number	:	513-618-0185
Fax Number	:	513-618-0186

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TIMOTHY CLARK
Credential	:
Telephone Number	:	937-428-7970

Provider Enumeration Date	:	01/05/2012
Last Update Date	:	12/13/2012

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Directions to “CLARKS RX LLC ” Practice Location

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