Provider Demographics
NPI:1205411832
Name:DAVIS, SIMONA (CPHT)
Entity Type:Individual
Prefix:
First Name:SIMONA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1427
Mailing Address - Country:US
Mailing Address - Phone:269-262-9820
Mailing Address - Fax:
Practice Address - Street 1:2107 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4060
Practice Address - Country:US
Practice Address - Phone:269-683-5573
Practice Address - Fax:269-683-7621
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303002939183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician