Provider Demographics
NPI:1972006005
Name:CLARK, MICHAEL RAYMOND
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
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 1:22118 N TUOLUMNE RD
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9605
Mailing Address - Country:US
Mailing Address - Phone:209-352-1411
Mailing Address - Fax:
Practice Address - Street 1:22629 TWAIN HARTE DR STE D
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9405
Practice Address - Country:US
Practice Address - Phone:209-586-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist