Provider Demographics
NPI:1952678617
Name:CLARK, MICHAEL J (RPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 LAUREL TOP DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5155
Mailing Address - Country:US
Mailing Address - Phone:804-349-4152
Mailing Address - Fax:
Practice Address - Street 1:5122 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-2422
Practice Address - Country:US
Practice Address - Phone:804-232-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist