Provider Demographics
NPI:1346519394
Name:DAVIS, HORTENSE A
Entity Type:Individual
Prefix:
First Name:HORTENSE
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SHELL COVE DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8106
Mailing Address - Country:US
Mailing Address - Phone:321-622-8003
Mailing Address - Fax:
Practice Address - Street 1:3650 MURRELL RD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4780
Practice Address - Country:US
Practice Address - Phone:321-735-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist