Organization
SOUTH STREET PHARMACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL STUART CLARK II (PHARMACIST OWNER)
(662) 843-6700
Entity
Organization
Contact information
Practice address
410 SOUTH ST, CLEVELAND, MS 38732-3450
(662) 843-6700
Mailing address
PO BOX 1748, 410 SOUTH STREET, CLEVELAND, MS 38732-1748
(662) 843-6700
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
05857
MS
3336C0003X
Community/Retail Pharmacy
Primary
—
—
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03181784
—
MS
05
—
04686806
—
MS
01
—
09058522
MEDICAID DME
MS
01
—
2521513
NABP NUMBER
MS
Enumeration date
12/11/2006
Last updated
03/20/2018
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