Provider Demographics
NPI:1003038894
Name:DUBOSE, CLARENCE E SR (RPH)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:E
Last Name:DUBOSE
Suffix:SR
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 1:3737 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-5107
Mailing Address - Country:US
Mailing Address - Phone:228-474-1011
Mailing Address - Fax:228-474-1033
Practice Address - Street 1:3737 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5107
Practice Address - Country:US
Practice Address - Phone:228-474-1011
Practice Address - Fax:228-474-1033
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE06041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist