Provider Demographics
NPI:1003048646
Name:DAVENPORT, ALISON GRAY (ALISON DAVENPORT)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:GRAY
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:ALISON DAVENPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 MONCK CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3173
Mailing Address - Country:US
Mailing Address - Phone:910-395-2201
Mailing Address - Fax:
Practice Address - Street 1:4502 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6163
Practice Address - Country:US
Practice Address - Phone:910-799-3162
Practice Address - Fax:910-452-1920
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-16
Last Update Date:2009-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC655952Medicaid