Provider Demographics
NPI:1376801290
Name:CLARK, MICHAEL ERICSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERICSON
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2062 WHISKEY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6183
Mailing Address - Country:US
Mailing Address - Phone:803-648-2339
Mailing Address - Fax:803-502-0971
Practice Address - Street 1:2062 WHISKEY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6183
Practice Address - Country:US
Practice Address - Phone:803-648-2339
Practice Address - Fax:803-502-0971
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC13704OtherPHARMACIST LICENSE