Provider Demographics
NPI:1467894766
Name:CLARK, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH SPRING
Mailing Address - State:AR
Mailing Address - Zip Code:72554-7466
Mailing Address - Country:US
Mailing Address - Phone:870-625-3222
Mailing Address - Fax:
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-7466
Practice Address - Country:US
Practice Address - Phone:870-625-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026461183500000X
ARPD12709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist