Provider Demographics
NPI:1457621021
Name:DAUGHERTY, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DAUGHERTY
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 1:2149 PINEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-8877
Mailing Address - Country:US
Mailing Address - Phone:314-517-6069
Mailing Address - Fax:
Practice Address - Street 1:6314 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7320
Practice Address - Country:US
Practice Address - Phone:850-476-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist