Provider Demographics
NPI:1144229212
Name:DAVIS, GLENN R (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 MARIELLA DR
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-2213
Mailing Address - Country:US
Mailing Address - Phone:606-674-6723
Mailing Address - Fax:
Practice Address - Street 1:632 SLATE AVE
Practice Address - Street 2:
Practice Address - City:OWINGSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40360-2206
Practice Address - Country:US
Practice Address - Phone:606-674-6386
Practice Address - Fax:606-674-3096
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist