Provider Demographics
NPI:1417394503
Name:CLARK, MICHAEL RAY (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 VALLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-2026
Mailing Address - Country:US
Mailing Address - Phone:205-995-0403
Mailing Address - Fax:205-408-7636
Practice Address - Street 1:2661 VALLEYDALE RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-2026
Practice Address - Country:US
Practice Address - Phone:205-995-0403
Practice Address - Fax:205-408-7636
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist