Healthcare Provider Details

I. General information

NPI: 1770531782
Provider Name (Legal Business Name): DAVID PETTY DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SOUTH Y SQUARE
SELMER TN
38375
US

IV. Provider business mailing address

1971 OLIVE HILL CHURCH LOOP
RAMER TN
38367-6123
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-6100
  • Fax: 731-645-4333
Mailing address:
  • Phone: 731-239-2717
  • Fax: 731-645-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7375
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: