Provider Demographics
NPI:1467833111
Name:DAVIDSON, KENDLE DWAYNE
Entity Type:Individual
Prefix:
First Name:KENDLE
Middle Name:DWAYNE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BYRDSTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38549-2323
Mailing Address - Country:US
Mailing Address - Phone:931-864-3166
Mailing Address - Fax:931-864-8166
Practice Address - Street 1:110 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BYRDSTOWN
Practice Address - State:TN
Practice Address - Zip Code:38549-2323
Practice Address - Country:US
Practice Address - Phone:931-864-3166
Practice Address - Fax:931-864-8166
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist