=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972104016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVERY CAMERON WOODALL PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2020
-----------------------------------------------------
Last Update Date | 11/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1224 HUNTSVILLE HWY
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37334-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-433-0011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2886 AL HIGHWAY 146
-----------------------------------------------------
City | SCOTTSBORO
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35768-5311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-244-4931
-----------------------------------------------------
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 | 21534
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 44259
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------