Provider Demographics
NPI:1174622930
Name:CLARK, MICHAEL STUART I
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STUART
Last Name:CLARK
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 SOUTH ST
Mailing Address - Street 2:PO BOX 1748
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3450
Mailing Address - Country:US
Mailing Address - Phone:662-843-6700
Mailing Address - Fax:662-846-6700
Practice Address - Street 1:410 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-3450
Practice Address - Country:US
Practice Address - Phone:662-843-6700
Practice Address - Fax:662-846-6700
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09058522OtherMEDICAID DME
MS2521513OtherNCPDP
MS04686806Medicaid
MS04686806Medicaid