Healthcare Provider Details

I. General information

NPI: 1306126057
Provider Name (Legal Business Name): LEWIS CLIFTON DEANHARDT JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 W MAIN ST
DOTHAN AL
36301-6402
US

IV. Provider business mailing address

2721 W MAIN ST
DOTHAN AL
36301-6402
US

V. Phone/Fax

Practice location:
  • Phone: 334-712-6205
  • Fax:
Mailing address:
  • Phone: 334-712-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10082
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: