Provider Demographics
NPI:1174113716
Name:CLARK, DOUGLAS (PHARMD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 S MCCOY DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25140 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-9775
Practice Address - Country:US
Practice Address - Phone:719-544-1371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist