MEDICARE: CLARKE TATJE POWELL 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	PS59719	FL

General Provider Information

NPI Number	:	1851948533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARKE TATJE POWELL PHARMD

Provider Business Mailing Address
First Line	:	304 W SILVERTHORN LN
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-7003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 FRONT ST
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5022
Country	:	US
Telephone Number	:	904-280-5440
Fax Number	:

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

Provider Enumeration Date	:	08/19/2019
Last Update Date	:	08/19/2019

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