Provider Demographics
NPI:1861762361
Name:CLARK, KATHY M
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 N TOLEDO BLADE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-2400
Mailing Address - Country:US
Mailing Address - Phone:941-429-6174
Mailing Address - Fax:941-429-8517
Practice Address - Street 1:1063 N TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-2400
Practice Address - Country:US
Practice Address - Phone:941-429-6174
Practice Address - Fax:941-429-8517
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-31
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist