Provider Demographics
NPI:1730776675
Name:CLARK, KATHRYN KAIB (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:KAIB
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 1:48 MEADOW GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5955
Mailing Address - Country:US
Mailing Address - Phone:770-355-7068
Mailing Address - Fax:
Practice Address - Street 1:2782 N COBB PKWY
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3472
Practice Address - Country:US
Practice Address - Phone:770-420-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35470183500000X
GA18707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist