Provider Demographics
NPI:1316423502
Name:DAVIDSON, MARC ALAN
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:ALAN
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 1:14720 THORNBIRD MANOR PKWY
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2497
Mailing Address - Country:US
Mailing Address - Phone:314-276-2459
Mailing Address - Fax:636-778-7878
Practice Address - Street 1:6920 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-2516
Practice Address - Country:US
Practice Address - Phone:314-721-3276
Practice Address - Fax:314-721-4394
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist