Provider Demographics
NPI:1649499146
Name:CLARK, PAUL GRAHAM
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:GRAHAM
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 1:418 COUNTY ROAD 804
Mailing Address - Street 2:
Mailing Address - City:GAMALIEL
Mailing Address - State:AR
Mailing Address - Zip Code:72537-9767
Mailing Address - Country:US
Mailing Address - Phone:870-467-5733
Mailing Address - Fax:
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2029
Practice Address - Country:US
Practice Address - Phone:417-256-9111
Practice Address - Fax:417-257-6727
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist