Provider Demographics
NPI:1285026237
Name:DAVIES, ROBERT THOMAS
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:DAVIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-6424
Mailing Address - Country:US
Mailing Address - Phone:850-968-3318
Mailing Address - Fax:
Practice Address - Street 1:1550 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-6424
Practice Address - Country:US
Practice Address - Phone:850-968-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9513183500000X
FLPS17364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106172000Medicaid