# SOUTH STREET PHARMACY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306906482
- **Authorized official:** MICHAEL STUART CLARK II (PHARMACIST OWNER)
- **Authorized official phone:** (662) 843-6700

## Contact information

- **Practice address:** 410 SOUTH ST, CLEVELAND, MS 38732-3450
- **Practice address phone:** (662) 843-6700
- **Mailing address:** PO BOX 1748, 410 SOUTH STREET, CLEVELAND, MS 38732-1748
- **Mailing address phone:** (662) 843-6700

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 183500000X | Pharmacist | 05857 | MS | — |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |
| 3336L0003X | Long Term Care Pharmacy | — | NULL | — |

## Other

- **Enumeration date:** 12/11/2006
- **Last updated:** 03/20/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 03181784 | — | MS |
| 05 | — | 04686806 | — | MS |
| 01 | — | 09058522 | MEDICAID DME | MS |
| 01 | — | 2521513 | NABP NUMBER | MS |