Provider Demographics
NPI:1053616813
Name:LARK, JOSEPH ANTHONY
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:LARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 S HEATON ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1207 S HEATON ST
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2311
Practice Address - Country:US
Practice Address - Phone:574-772-4529
Practice Address - Fax:574-772-7962
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017681A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist