Provider Demographics
NPI:1497027171
Name:DAVIS, SAMUEL MARK (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MARK
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3404
Mailing Address - Country:US
Mailing Address - Phone:563-332-6049
Mailing Address - Fax:563-332-6162
Practice Address - Street 1:3425 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3404
Practice Address - Country:US
Practice Address - Phone:563-332-6049
Practice Address - Fax:563-332-6162
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14533183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14533OtherIOWA BOARD OF PHARMACY
IL051.031876OtherDEPT OF PROFESSIONAL REGULATION