Provider Demographics
NPI:1982207049
Name:HURST, CLIFFORD STEWART I
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:STEWART
Last Name:HURST
Suffix:I
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 1:2720 HIGHWAY 42 N
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4301
Mailing Address - Country:US
Mailing Address - Phone:678-432-9450
Mailing Address - Fax:678-432-3029
Practice Address - Street 1:2720 HIGHWAY 42 N
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4301
Practice Address - Country:US
Practice Address - Phone:678-432-9450
Practice Address - Fax:678-432-3029
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist