Provider Demographics
NPI:1144788498
Name:WILLIAMS, DORA JO
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:JO
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-0774
Mailing Address - Country:US
Mailing Address - Phone:606-932-3614
Mailing Address - Fax:606-932-3614
Practice Address - Street 1:437 JAMES E HANNAH DR
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-9600
Practice Address - Country:US
Practice Address - Phone:606-932-3614
Practice Address - Fax:606-932-3614
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist