Provider Demographics
NPI:1083156863
Name:DAVIS BROTHERS PHARMACY INC
Entity Type:Organization
Organization Name:DAVIS BROTHERS PHARMACY INC
Other - Org Name:DAVIS BROTHERS PHARMACY - CHESTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-670-8107
Mailing Address - Street 1:559 CAROLINA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:WV
Mailing Address - Zip Code:26034-1364
Mailing Address - Country:US
Mailing Address - Phone:304-387-1741
Mailing Address - Fax:304-387-1741
Practice Address - Street 1:559 CAROLINA AVE STE B
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:WV
Practice Address - Zip Code:26034-1364
Practice Address - Country:US
Practice Address - Phone:304-387-1741
Practice Address - Fax:304-387-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552508333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1083156863Medicaid
2166220OtherPK