1063526036 NPI number — DAVIS PHARMACY INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063526036 NPI number — DAVIS PHARMACY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVIS PHARMACY INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063526036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 MOTT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW MADRID
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63869-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 MOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW MADRID
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63869-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-748-5205
Provider Business Practice Location Address Fax Number:
573-748-2838
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
573-748-5205

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 003656 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 600133805 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2609040 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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