Provider Demographics
NPI:1356944003
Name:CLARK, ROBERT JUSTIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JUSTIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-0478
Mailing Address - Country:US
Mailing Address - Phone:662-356-4000
Mailing Address - Fax:662-356-4044
Practice Address - Street 1:741 MAIN ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MS
Practice Address - Zip Code:39740-7609
Practice Address - Country:US
Practice Address - Phone:662-356-4000
Practice Address - Fax:662-356-4044
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-11912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist