Provider Demographics
NPI:1164989539
Name:DAVIDSON, JOHN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 OLD CASS WHITE RD NW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-4724
Mailing Address - Country:US
Mailing Address - Phone:770-547-3205
Mailing Address - Fax:
Practice Address - Street 1:2688 HIGHWAY 411 SE
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:GA
Practice Address - Zip Code:30139-2924
Practice Address - Country:US
Practice Address - Phone:706-337-5541
Practice Address - Fax:706-337-5461
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist