Provider Demographics
NPI:1043350358
Name:CLARKE, MICHAEL HISCOCK (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HISCOCK
Last Name:CLARKE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9436 FREEDOM WAY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6311
Mailing Address - Country:US
Mailing Address - Phone:505-727-2897
Mailing Address - Fax:505-727-9302
Practice Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-727-2897
Practice Address - Fax:505-727-9302
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist