MEDICARE: RANDY WARD DAVIDSON PHT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	T01889	AL

General Provider Information

NPI Number	:	1134297120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY WARD DAVIDSON PHT

Provider Business Mailing Address
First Line	:	P O BOX 185
Second Line	:
City	:	MCINTOSH
State	:	AL
Zip	:	36553-0185
Country	:	US
Telephone Number	:	251-944-0143
Fax Number	:	251-944-8226

Provider Business Practice Location Address
First Line	:	61 RIVER RD
Second Line	:
City	:	MCINTOSH
State	:	AL
Zip	:	36553-0247
Country	:	US
Telephone Number	:	251-944-2563
Fax Number	:	251-944-3080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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