Provider Demographics
NPI:1609467356
Name:HENDERSON, LEE WALT (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:WALT
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 DANVILLE RD SW STE J
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-4221
Mailing Address - Country:US
Mailing Address - Phone:256-353-1121
Mailing Address - Fax:256-353-1790
Practice Address - Street 1:2422 DANVILLE RD SW STE J
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-4221
Practice Address - Country:US
Practice Address - Phone:256-353-1121
Practice Address - Fax:256-353-1790
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist