Provider Demographics
NPI:1235676776
Name:CLARK, WILLIAM RAYMOND
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RAYMOND
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:25 TEEL MOUNTAIN WAY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-0719
Mailing Address - Country:US
Mailing Address - Phone:770-490-1488
Mailing Address - Fax:
Practice Address - Street 1:55 HELEN HWY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1092
Practice Address - Country:US
Practice Address - Phone:706-348-1571
Practice Address - Fax:706-348-1823
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist