Provider Demographics
NPI:1780905505
Name:CLARK, MICHAEL E (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
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 1:57 HILLCREST CT
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1607
Mailing Address - Country:US
Mailing Address - Phone:415-239-2850
Mailing Address - Fax:
Practice Address - Street 1:200 FAIRMONT SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-1240
Practice Address - Country:US
Practice Address - Phone:650-355-5810
Practice Address - Fax:650-355-5882
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist