MEDICARE: MR. LEWIS GRANT CLARK III PHARMACIST

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	GA 11041	GA

General Provider Information

NPI Number	:	1558352377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEWIS GRANT CLARK III PHARMACIST

Provider Business Mailing Address
First Line	:	815 SAINT MARYS DR
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31501-3234
Country	:	US
Telephone Number	:	912-338-0688
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 SAINT MARYS DR
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31501-3234
Country	:	US
Telephone Number	:	912-338-0688
Fax Number	:

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

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	07/08/2007

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