MEDICARE: MICHAEL STUART CLARK I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	05857	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2521513	OTHER	MS	NCPDP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174622930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL STUART CLARK I

Provider Business Mailing Address
First Line	:	410 SOUTH ST
Second Line	:	PO BOX 1748
City	:	CLEVELAND
State	:	MS
Zip	:	38732-3450
Country	:	US
Telephone Number	:	662-843-6700
Fax Number	:	662-846-6700

Provider Business Practice Location Address
First Line	:	410 SOUTH ST
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-3450
Country	:	US
Telephone Number	:	662-843-6700
Fax Number	:	662-846-6700

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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Directions to “ MICHAEL STUART CLARK I ” Practice Location

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