Provider Demographics
NPI:1164763124
Name:CLARK, MICHAEL T (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5512
Mailing Address - Country:US
Mailing Address - Phone:512-442-1578
Mailing Address - Fax:512-444-4255
Practice Address - Street 1:2400 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5512
Practice Address - Country:US
Practice Address - Phone:512-442-1578
Practice Address - Fax:512-444-4255
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist