Provider Demographics
NPI:1326712142
Name:DAVIS, CODY MICHAEL
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:MICHAEL
Last Name:DAVIS
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 1:646 CATHY ANN DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6552
Mailing Address - Country:US
Mailing Address - Phone:330-770-7943
Mailing Address - Fax:
Practice Address - Street 1:613 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1335
Practice Address - Country:US
Practice Address - Phone:330-875-1429
Practice Address - Fax:330-875-2753
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03440953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03440953OtherOHIO STATE BOARD OF PHARMACY