MEDICARE: MR. MICHAEL JOHN CLARK RPH

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	12691-040	WI

General Provider Information

NPI Number	:	1386920239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL JOHN CLARK RPH

Provider Business Mailing Address
First Line	:	1979 LIME KILN RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-6219
Country	:	US
Telephone Number	:	920-288-0638
Fax Number	:	920-288-0645

Provider Business Practice Location Address
First Line	:	1979 LIME KILN RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-6219
Country	:	US
Telephone Number	:	920-288-0638
Fax Number	:	920-288-0645

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

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	10/24/2011

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