Provider Demographics
NPI:1770531782
Name:PETTY, DAVID (DPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1971 OLIVE HILL CHURCH LOOP
Mailing Address - Street 2:
Mailing Address - City:RAMER
Mailing Address - State:TN
Mailing Address - Zip Code:38367-6123
Mailing Address - Country:US
Mailing Address - Phone:731-239-2717
Mailing Address - Fax:731-645-4333
Practice Address - Street 1:103 SOUTH Y SQUARE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375
Practice Address - Country:US
Practice Address - Phone:731-645-6100
Practice Address - Fax:731-645-4333
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist