Provider Demographics
NPI:1730403783
Name:CLARK, LINDA SUE (RPH)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 BASIL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1813
Mailing Address - Country:US
Mailing Address - Phone:304-342-8271
Mailing Address - Fax:
Practice Address - Street 1:201 CROSSINGS MALL
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071
Practice Address - Country:US
Practice Address - Phone:304-965-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist