Provider Demographics
NPI:1720196645
Name:HENDERSON, DAVID WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203-3944
Mailing Address - Country:US
Mailing Address - Phone:256-835-6695
Mailing Address - Fax:256-831-8398
Practice Address - Street 1:1408 GOLDEN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-6924
Practice Address - Country:US
Practice Address - Phone:256-831-9960
Practice Address - Fax:256-831-8398
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10834OtherLICENSE NUMBER