Provider Demographics
NPI:1356440820
Name:CLARK, JAMES MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
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 1:3040 CREST DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1429
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:
Practice Address - Street 1:10,000 BAY PINES BLVD.
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist