Provider Demographics
NPI:1104160308
Name:TUCKER, DAVID G (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:G
Last Name:TUCKER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PEAR LN
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-4368
Mailing Address - Country:US
Mailing Address - Phone:662-312-6780
Mailing Address - Fax:
Practice Address - Street 1:220 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3762
Practice Address - Country:US
Practice Address - Phone:662-323-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST8457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist