Provider Demographics
NPI:1073620464
Name:DAVIS, MARY L (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3816
Mailing Address - Country:US
Mailing Address - Phone:304-723-2656
Mailing Address - Fax:304-723-2657
Practice Address - Street 1:265 PENCO RD
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3816
Practice Address - Country:US
Practice Address - Phone:304-723-2656
Practice Address - Fax:304-723-2657
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist