Provider Demographics
NPI:1972842417
Name:FORD, DWIGHT DAVID
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:DAVID
Last Name:FORD
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 1:41 STONEBROOK PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3637
Mailing Address - Country:US
Mailing Address - Phone:731-661-0912
Mailing Address - Fax:731-661-0914
Practice Address - Street 1:41 STONEBROOK PL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3637
Practice Address - Country:US
Practice Address - Phone:731-661-0912
Practice Address - Fax:731-661-0914
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN64611835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist