Provider Demographics
NPI:1396182655
Name:WILLIAMS, DANESHA
Entity Type:Individual
Prefix:
First Name:DANESHA
Middle Name:
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 1:54 COUNTY ROAD 2621
Mailing Address - Street 2:
Mailing Address - City:SHUBUTA
Mailing Address - State:MS
Mailing Address - Zip Code:39360-9056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W MOULTRIE DR
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1716
Practice Address - Country:US
Practice Address - Phone:870-763-7958
Practice Address - Fax:870-763-7958
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist