Provider Demographics
NPI:1013294461
Name:CLARK DRUG COMPANY, LLC
Entity type:Organization
Organization Name:CLARK DRUG COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:662-356-4000
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-0478
Mailing Address - Country:US
Mailing Address - Phone:662-356-4000
Mailing Address - Fax:662-356-4044
Practice Address - Street 1:741 MAIN ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MS
Practice Address - Zip Code:39740-7609
Practice Address - Country:US
Practice Address - Phone:662-356-4000
Practice Address - Fax:662-356-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09552/1.13336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03406798Medicaid
MS03406798Medicaid