=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780905505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E CLARK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2010
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 FAIRMONT SHOPPING CTR
-----------------------------------------------------
City | PACIFICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94044-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-355-5810
-----------------------------------------------------
Fax | 650-355-5882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 HILLCREST CT
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94127-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-239-2850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28890
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------