Provider Demographics
NPI:1801271689
Name:DAVIDSON, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:DAVIDSON
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 1:1298 165TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-8364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-8724
Practice Address - Country:US
Practice Address - Phone:620-223-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-10254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist