Provider Demographics
NPI:1487922985
Name:CLARK, CASSANDRA R (PHARMD)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 TOMPIRO DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1377
Mailing Address - Country:US
Mailing Address - Phone:505-610-9332
Mailing Address - Fax:
Practice Address - Street 1:1900 BATAAN MEMORIAL E
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-6011
Practice Address - Country:US
Practice Address - Phone:575-522-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist