Provider Demographics
NPI:1093316317
Name:DAVIS, LATISHA NADINE
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:NADINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0572
Mailing Address - Country:US
Mailing Address - Phone:606-207-6544
Mailing Address - Fax:
Practice Address - Street 1:1589 KY HWY 15 SOUTH
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist