Healthcare Provider Details

I. General information

NPI: 1467833111
Provider Name (Legal Business Name): KENDLE DWAYNE DAVIDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HILLCREST DR
BYRDSTOWN TN
38549-2323
US

IV. Provider business mailing address

110 HILLCREST DR
BYRDSTOWN TN
38549-2323
US

V. Phone/Fax

Practice location:
  • Phone: 931-864-3166
  • Fax: 931-864-8166
Mailing address:
  • Phone: 931-864-3166
  • Fax: 931-864-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3783
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: