Provider Demographics
NPI:1649581430
Name:HENDERSON, ROBERT OWEN JR (DRPH)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:OWEN
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:DRPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 OIL WELL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7929
Mailing Address - Country:US
Mailing Address - Phone:731-664-8892
Mailing Address - Fax:731-664-9195
Practice Address - Street 1:384 OIL WELL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-7929
Practice Address - Country:US
Practice Address - Phone:731-664-8892
Practice Address - Fax:731-664-9195
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1063429082OtherNPI #WALGREENS STORE 9835