Provider Demographics
NPI:1104414523
Name:DAVIDSON, KEN SEARCY (RPH)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:SEARCY
Last Name:DAVIDSON
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 1:1238A HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9468
Mailing Address - Country:US
Mailing Address - Phone:870-955-1022
Mailing Address - Fax:870-955-5052
Practice Address - Street 1:1238A HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9468
Practice Address - Country:US
Practice Address - Phone:870-955-1022
Practice Address - Fax:870-955-5052
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR236370407Medicaid