Provider Demographics
NPI:1144869900
Name:CLARK, SAMANTHA JANE (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
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 1:2174 S CORTLAND VIRGIL RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-8984
Mailing Address - Country:US
Mailing Address - Phone:607-745-1877
Mailing Address - Fax:
Practice Address - Street 1:79 NORTH ST
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-8510
Practice Address - Country:US
Practice Address - Phone:607-844-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist