Provider Demographics
NPI:1972679868
Name:HENDERSON, DAVID WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WILLIAM
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 1:523 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MO
Mailing Address - Zip Code:65254
Mailing Address - Country:US
Mailing Address - Phone:660-338-2125
Mailing Address - Fax:660-338-2045
Practice Address - Street 1:523 FIRST ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MO
Practice Address - Zip Code:65254
Practice Address - Country:US
Practice Address - Phone:660-338-2125
Practice Address - Fax:660-338-2045
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO041733OtherPHARMACIST