Provider Demographics
NPI:1083648364
Name:HUDSON, DAVID CHARLES (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:HUDSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 HIGHWAY 43 N
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3372
Mailing Address - Country:US
Mailing Address - Phone:662-289-3234
Mailing Address - Fax:662-289-3030
Practice Address - Street 1:109 NORTHSIDE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090
Practice Address - Country:US
Practice Address - Phone:662-289-3234
Practice Address - Fax:662-289-3030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07439318Medicaid