Provider Demographics
NPI:1174931513
Name:CLARK, ERIKKA
Entity type:Individual
Prefix:
First Name:ERIKKA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 DUCK POND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1633
Practice Address - Country:US
Practice Address - Phone:802-748-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0104359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT033.0104359OtherPHARMACIST LICENSE