Basic Information
| Provider Information | |||||||||
| NPI: | 1235757915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8423 SW POINTER WAY APT M | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972257316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413015735 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4400 NE HALSEY ST STE 490 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972131545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038936900 | ||||||||
| FaxNumber: | 5034873595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | RPH-0017464 | OR | Y |
No ID Information.