=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598908303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID T NANCE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2009
-----------------------------------------------------
Last Update Date | 04/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 MILGEN RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31907-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-561-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 79 DOVE DR
-----------------------------------------------------
City | FORTSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31808-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-327-0551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH011523
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------