Provider Demographics
NPI:1114083094
Name:DAVIS PHARMACY
Entity Type:Organization
Organization Name:DAVIS PHARMACY
Other - Org Name:DAVIS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-746-3721
Mailing Address - Street 1:59 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:E MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04430-1126
Mailing Address - Country:US
Mailing Address - Phone:207-746-3721
Mailing Address - Fax:207-746-9230
Practice Address - Street 1:59 MAIN ST
Practice Address - Street 2:
Practice Address - City:E MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04430-1126
Practice Address - Country:US
Practice Address - Phone:207-746-3721
Practice Address - Fax:207-746-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MEPH500003053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME999101731Medicaid
2036558OtherPK
1180880001Medicare NSC