Provider Demographics
NPI:1619269602
Name:CLARK, JOE H (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:H
Last Name:CLARK
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 1:11470 KATIE DR
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-5305
Mailing Address - Country:US
Mailing Address - Phone:228-255-2886
Mailing Address - Fax:
Practice Address - Street 1:11470 KATIE DR
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-5305
Practice Address - Country:US
Practice Address - Phone:228-255-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE05858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist