Provider Demographics
NPI:1871889519
Name:CLARK, KARRIE SHAFFER
Entity type:Individual
Prefix:
First Name:KARRIE
Middle Name:SHAFFER
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 1:2585 TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-7901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5471 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1374
Practice Address - Country:US
Practice Address - Phone:336-744-2321
Practice Address - Fax:336-744-2329
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist