1427163625 NPI number — CLARK PHARMACY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427163625 NPI number — CLARK PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427163625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 W MONTGOMERY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77378-8827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-856-4594
Provider Business Practice Location Address Fax Number:
936-856-3512
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 24189 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4510687 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 140591 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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