Healthcare Provider Details

I. General information

NPI: 1134297120
Provider Name (Legal Business Name): RANDY WARD DAVIDSON PHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 RIVER RD
MCINTOSH AL
36553-0247
US

IV. Provider business mailing address

P O BOX 185
MCINTOSH AL
36553-0185
US

V. Phone/Fax

Practice location:
  • Phone: 251-944-2563
  • Fax: 251-944-3080
Mailing address:
  • Phone: 251-944-0143
  • Fax: 251-944-8226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT01889
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: