Active NPI
Michael Stuart Clark I
- Pharmacist
- Cleveland, MS
National Provider Identifier
1174622930
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 05857
- Practice address
- 410 South St
Cleveland, MS 38732-3450 - Phone
- (662) 843-6700
- Fax
- (662) 846-6700
- NPI assigned
- Sep 21, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 05857 | MS | Primary |
Addresses
Primary practice location
410 South St
Cleveland, MS 38732-3450
Mailing address
410 South St
PO Box 1748
Cleveland, MS 38732-3450
Phone (662) 843-6700
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04686806 | Medicaid | MS | |
| 09058522 | Other | MS | MEDICAID DME |
| 2521513 | Other | MS | NCPDP |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 05857 | MS | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| South Street Pharmacy | Pharmacist | Current | Accepting new patients |
Locations
410 South St
Cleveland, MS 38732
Phone (662) 843-6700
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158796800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1174622930",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "410 SOUTH ST",
"address_2": "PO BOX 1748",
"city": "CLEVELAND",
"state": "MS",
"postal_code": "387323450",
"telephone_number": "662-843-6700",
"fax_number": "662-846-6700"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "410 SOUTH ST",
"city": "CLEVELAND",
"state": "MS",
"postal_code": "387323450",
"telephone_number": "662-843-6700",
"fax_number": "662-846-6700"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "MICHAEL",
"middle_name": "STUART",
"name_suffix": "I",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-09-21",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MS",
"license": "05857",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "04686806",
"state": "MS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICAID DME",
"identifier": "09058522",
"state": "MS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NCPDP",
"identifier": "2521513",
"state": "MS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Cleveland, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.