Provider Demographics
NPI:1255734125
Name:WARD, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WARD
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:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-0769
Mailing Address - Country:US
Mailing Address - Phone:910-754-7200
Mailing Address - Fax:910-754-7555
Practice Address - Street 1:58 PHYSICIANS DR NW STE 5
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4215
Practice Address - Country:US
Practice Address - Phone:910-754-7200
Practice Address - Fax:910-754-7555
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0105470Medicaid
3405669OtherNCPDP
NC0105470Medicaid