Provider Demographics
NPI:1407123649
Name:DAVIS, JOHN R (R PH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6608 GEORGE WASHINGTON MEM HWY
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4801
Mailing Address - Country:US
Mailing Address - Phone:757-890-9402
Mailing Address - Fax:
Practice Address - Street 1:6608 GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-4801
Practice Address - Country:US
Practice Address - Phone:757-890-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist