Provider Demographics
NPI:1356446561
Name:DAVIS, GARY LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43724-1359
Mailing Address - Country:US
Mailing Address - Phone:740-732-4503
Mailing Address - Fax:740-732-2272
Practice Address - Street 1:109 WEST STREET
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:OH
Practice Address - Zip Code:43724-1359
Practice Address - Country:US
Practice Address - Phone:740-732-4503
Practice Address - Fax:740-732-2272
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03216592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0872882Medicaid
OH0242860001Medicare ID - Type Unspecified