Healthcare Provider Details

I. General information

NPI: 1881771533
Provider Name (Legal Business Name): MISTY DAWN CLARK R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 ALABAMA HIGHWAY 20
TOWN CREEK AL
35672
US

IV. Provider business mailing address

223 FAWN LN
KILLEN AL
35645-8383
US

V. Phone/Fax

Practice location:
  • Phone: 256-685-3530
  • Fax: 256-685-3523
Mailing address:
  • Phone: 256-272-0556
  • Fax: 256-272-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13766
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: