Basic Information
| Provider Information | |||||||||
| NPI: | 1457481897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278561743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349170142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 GREEN ST E | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278934105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522439800 | ||||||||
| FaxNumber: | 2522439888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 18217 | NC | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.