Provider Demographics
NPI:1477158194
Name:CLARK, CLAYTON (PHARMD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
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 1:438 ANCHORAGE RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6059
Mailing Address - Country:US
Mailing Address - Phone:901-233-0190
Mailing Address - Fax:
Practice Address - Street 1:1912 JACKSON AVE W
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4454
Practice Address - Country:US
Practice Address - Phone:662-238-3427
Practice Address - Fax:662-248-3432
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE15108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist