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General NPI Number Information
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NPI Number | 1649499146
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Entity Type | Individual
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Provider Name | MR. PAUL GRAHAM CLARK
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Gender | Male
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1100 N KENTUCKY AVE
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City | WEST PLAINS
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State | MO
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Zip | 65775-2029
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Country | US
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Telephone | 417-256-9111
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Fax | 417-257-6727
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Provider Business Mailing Address
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Address Line | 418 COUNTY ROAD 804
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City | GAMALIEL
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State | AR
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Zip | 72537-9767
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Country | US
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Telephone | 870-467-5733
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 044351
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License Number State | MO
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