Provider Demographics
NPI:1407853260
Name:CLONINGER, MARK (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CLONINGER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 NARRON FARM RD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-5730
Mailing Address - Country:US
Mailing Address - Phone:919-269-4495
Mailing Address - Fax:
Practice Address - Street 1:98 DODD STREET
Practice Address - Street 2:
Practice Address - City:SPRING HOPE
Practice Address - State:NC
Practice Address - Zip Code:27882
Practice Address - Country:US
Practice Address - Phone:252-478-5969
Practice Address - Fax:252-478-2978
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0645440Medicaid
NC0645440Medicaid