Provider Demographics
NPI:1487609111
Name:CLARK, CRAIG LEO (RPH)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:LEO
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402
Mailing Address - Country:US
Mailing Address - Phone:319-393-3210
Mailing Address - Fax:319-393-2747
Practice Address - Street 1:1946 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-393-3210
Practice Address - Fax:319-393-2747
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist