MEDICARE: MICHAEL J CLARK

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	2013026461	MO
2	183500000X	Pharmacist	PD12709	AR

General Provider Information

NPI Number	:	1467894766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J CLARK

Provider Business Mailing Address
First Line	:	270 MAIN ST
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-7466
Country	:	US
Telephone Number	:	870-625-3222
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 MAIN ST
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-7466
Country	:	US
Telephone Number	:	870-625-3222
Fax Number	:

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

Provider Enumeration Date	:	07/27/2013
Last Update Date	:	11/27/2020

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