Provider Demographics
NPI:1558352377
Name:CLARK, LEWIS GRANT III (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:GRANT
Last Name:CLARK
Suffix:III
Gender:M
Credentials:PHARMACIST
Other - Prefix:MR
Other - First Name:LEWIS
Other - Middle Name:GRANT
Other - Last Name:CLARK
Other - Suffix:V
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:815 SAINT MARYS DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3234
Mailing Address - Country:US
Mailing Address - Phone:912-338-0688
Mailing Address - Fax:
Practice Address - Street 1:815 SAINT MARYS DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3234
Practice Address - Country:US
Practice Address - Phone:912-338-0688
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 11041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist