Provider Demographics
NPI:1134297120
Name:DAVIDSON, RANDY WARD (PHT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:WARD
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 185
Mailing Address - Street 2:
Mailing Address - City:MCINTOSH
Mailing Address - State:AL
Mailing Address - Zip Code:36553-0185
Mailing Address - Country:US
Mailing Address - Phone:251-944-0143
Mailing Address - Fax:251-944-8226
Practice Address - Street 1:61 RIVER RD
Practice Address - Street 2:
Practice Address - City:MCINTOSH
Practice Address - State:AL
Practice Address - Zip Code:36553-0247
Practice Address - Country:US
Practice Address - Phone:251-944-2563
Practice Address - Fax:251-944-3080
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT01889183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician